fmdaru wxl / Form No.

iKi ,hs*a bkaIqjrkaia lïmeks mS t,a iS

^j¾I 2007 wxl 07 orK iud.ï mk; hgf;a kS;s.;hs&
SANASA LIFE INSURANCE COMPANY PLC
(Registered Under the Companies Act 07 of 2007)

wxl 340 2$1" wd¾' ta' o fu,a udj;" fld<U 03

Tmamq wxlh(
fhdackd wxlh( No. 340 2/1, R. A. De Mel Mawatha, Colombo 03 Policy No.
Proposal No. ÿrl:k /Tel: 011-2002021 *elaia /Tel: 011-2574705

iKi Kh iqrel=ï rCIKh i`oyd fhdackd m;%h

PROPOSAL FOR SANASA LOAN PROTECTION
ish`tu ms<s;=re wl=ßka úh hq;=h' bß .id wvq mdvq iys;j tjkq ,nk fhdackd m;% ndr.kq fkd,efí'
All answers should be in words, Strokes, dots or dashes are not be asserted as answers.

Agents name Agent's code

ksfhdacs;hdf.a ku ksfhdacs; wxlh
Sales promotion officers name SPO code
wf,ú m%j¾Ok ks,Odßhdf.a ku wf,ú m%j¾Ok ks,Odßhdf.a wxlh
Branch/District
Name of society, address and code YdLdj$Èia;s%lalh
iñ;sfha ku" ,smskh iy wxlh
Proposal number
fhdackd wxlh

Answer all questions to the best of your knowledge and belief. Benefits under the policy may not be payable in the event of non disclosure or misrepresentation. If you are in doubt
about the relevance of certain facts, it is in your interest to disclose them.
Tnf.a oekqu iy úYajdih u; mokïj ish¨ m%YaK j,g ms<s;=re imhkak' lreKq fy<s fkdlsÍu fyda jerÈ f,i lreKq ±laùu m%;s,dN wysñùug fya;= úh yelshs' lsishï lreKla
wod, ùu ms<sn`o ielhla mj;Skï th fy<s lsÍu Tnf.a hym;g fya;= jkq we;'

1. Name in Full (block letters) Mr. /Mrs. /Miss

iïmQ¾K ku ^lemsg,a& uhd$ñh$fukúh

2. Address 3. Telephone office/ld¾hd,Sh

,smskh ÿrl:k
Home/ksji

Whatsapp/Mobile/cx.u
4. E-mail/úoHq;a ;emE,

5. Facebook Account / f*aianqla .sKqu 7. NIC Number

ye`ÿkïm;a wxlh
6. Date of Birth D D M M Y Y Y Y 9. Occupation / /lshdj
Wmka Èkh

8. Civil Status/ újdyl-wújdyl nj 10. Monthly income / udisl wdodhu

11. Weight/ nr ^lsf,da.%Eï& 12. Height (ft.)/ Wi ^wä&

lreKdlr ^√& i,l=K fhdod ms<s;=r igyka lrkak'

Please mark with a tick “ √ “

13. Are you suffering from or have you ever suffered from any accident, Illness, disease or ailment which required hospitalization, nursing care surgery which led to
Yes/Tõ No/ke;
residual disability of any sort
Tn frday,a.; úh hq;= fyda idhksl m%;sldr i`oyd fhduqúh hq;= lsishï yÈis wk;=rlska" wikSm ;;a;ajhlska fyda frda.dndOhlska fmf<kjdo@ fyda Ndckh
ù we;ao@ ke;skï ks;H wl¾uKh;d ;;a;ajhlska isào@$isáfhao@

14. Are you currently under treatment or medication or have you, in the past years been advised to undergo surgery, medical investigation or medical treatment for Yes/Tõ No/ke;
any medical condition other than minor conditions like cold, flu, etc.
fiïm%;sYHdj" bka*a¨fjkaidj jeks iq¿ wikSm ;;a;ajhka yerKqfldg miq.sh jir lsysmh ;=< ffjoH m%;sldr" ie;alï" ffjoH úYaf,aIK i`oyd fhduqù
;sfío@'
15. Are you suffering /have you ever suffered from or have you ever been diagnosed / received treatment for medical conditions such as
High blood pressure, diabetes, chest pain, heart attack/ any other heart condition, stroke transient ischemic attack / any other cerebrovascular disease/ any
other endocrinal disease , kidney disease, HIV AIDS/ AIDS related complexity, cancer/ tumor , asthma/ any other respiratory disease, any mental/ nervous
disease, hepatitis/ any other liver disease , blood disorders digestive disorders, paraplegia/ any other disorder of bones/ spine/ muscle
Tn my; lsishï fyda frda.dndOhlska mSvd ú`Èñka isáfhao@ ke;fyd;a ta ms<sno ffjoH ks.ukhlg t<eT m%;sldr ,nñka isákafkao@
Yes/Tõ No/ke;
wê reêr mSvkh" Èhjeähdj" mmqfõ fõokd" yDohdndOh fjk;a yDoh wdY%s; frda." reêr kd, wNHka;r frda.dndO" jl=.vq frda." tÉ'whs'ù' taâia" ta wdY%s;
ixl+,;d" ms<sld$áhqu¾" weÿu$fjk;a Yajik wdY%s; frda.dndO" udkisl frda.$iakdhq wndO" fymghsáia$wlaud wdY%s; frda.dndO" reêr ixl+,;d" wdydr Ô¾K
moaO;sfha ixl+,;d" mr fi.sßh$wfkl=;a wiaÓ$fldkao$udxY fmaYs wdY%s; frda.dndO'
16. Has your any application / Proposal for Life, Health, Accident/ Critical illness including renewal and reinstatement ever been declined /deferred / withdrawn /
Yes/Tõ No/ke;
accepted at special rates/ erms with exclusions by any life insurance company
ñka fmr Tnf.a Ôú;" fi!LHh" yosis wk;=re$ nrm;< frda.dndO ms<sn| rlaIK fhdackd" lsishï rlaIK wdh;khlska kej; ia:dms; lsÍu$w¨;a lsÍu
fudkhï wdldrhlg fyda m%;slafIam ù$úfYaI kshuhka$fmd<S u; ms<sf.k ;sfío@
Please complete below table if, your answer is “yes” to any question from No. 13 - 16
by; wxl 13 - 16 olajd jQ m%Yakhla i|yd ^Tõ& f,i ms<s;=re ,nd ÿkafka kï muKla my; j.=j iïmQ¾K lrkak'
Treatment date Diagnosis/ Treatment Duration ffjoHjrhdf.a ku Address of the Doctor/ Hospital Other
m%;sldr ,nd.;a oskh frda.h$m%;sldrh ld, iSudj Name of the doctor ffjoHjrhdf.a$frday,a ,smskh fjk;a úia;r
Please mark with a tick (√ )
lreKdlr ^√& i,l=K fhdod ms<s;=r igyka lrkak'
17. (a) Do you have any intention of engaging in any hazardous occupation or sport? if "yes" give details
Tn wk;=reodhl l%Svdjl fyda /lshdjl fh§ug n,dfmdfrd;a;= jkafkao@ ˜Tõ˜ kï úia;r imhkak' Yes/Tõ No/ke;

(b) Have you been convicted of any criminal offences? Are there any criminal proceedings instituted and/ pending against you?
hï idmrdê jrola iïnkaOfhka Tn jrolre ù we;ao@ tjekakla iïnkaOfhka Tng úreoaOj kvqjla mjrd fyda úNd. fjñka mj;So@ Yes/Tõ No/ke;

(c) Do you have or had any kind of threat on your life?

Yes/Tõ No/ke;
Tnf.a cSú;hg hï ;¾ckhla ±kg ;sfío@ óg fmr ;sî we;ao@

Please provide details if your answer is “yes” to the above

by; Tnf.a ms<s;=r ^Tõ& kï lreKdlr ta ms<sno úia;r imhkak'

No. / wkq wxlh Details / úia;rh

(a)

(b)

(c)

Daily consumption (ml)

17. (a) Do you use over have used alcohol? If so Èklg tAll m%udKh ^ñ,s ,Sgr&
Tn uOHidr Ndjs;d lrkafkao@ tfia kï
Avarage days of usage per month
uilg jdr .Kk
How many cigarettes do you consume per day
(b) Have you smoked tabacco in the last 12 months? If so Èklg Ndjs;d lrk ÿï jeá m%udKh
miq.sh 12 ui ;=< Tn ÿïfld, mdkh lr ;sfío@ tfia kï Avarage days of usage per month
uilg jdr .Kk
(c) Do you use or ever have used narcotic drugs?
Tn u;aøjH Ndú;d lrkafkao@
(d) Have you ever taken drugs for other than medical purposes?
Tn ljod fyda ffjoH fya;=ka u; yereKq úg T!IO mdúÉÑ lr ;sfío@

I being the life to be assured, declare that all statements made above are true to the best of my knowledge and belief. I consent to the company seeking information from the lending
institute and also from any doctor who at any time has attendend on me concerning anything which affects my physical or mental health or seeking information from any insurer on
my life.
SANASA Life Insurance company PLC shall not be liable for any claim on account of illness, injury or cause of which was known prior to approval of my request for assurance and have
not withheld or concealed anything in the above statements. Further, I authorise any representative of SANASA Life Insurance company PLC to obtain the head ticket or any other
clinical notes from any private or government hospital, clinic or nursing home if necessary.
uu by; i`oyka ish¿u m%ldY udf.a wkq ±kqu yd úYajdih u; ks;H nj m%ldY lrñ' udf.a fi!LH ;;a;ajh flfrys n,md we;s ljr fyda lreKla i`oyd lsishï ld,hl hïlsis

Addition to AWPLR ( If floating)

m%;sldr lr we;s hïlsis ffjoHjrfhl=f.a ffjoH f;dr;=re ,nd.ekSug" tfiau we`o by m; jd¾:djla fyda fjk;a idhksl jd¾;djla ,nd .ekSug udf.a wkque;sh foñ' ke;fyd;a
udf.a cSú;h ms<sn`o hïlsis rCIK ld¾hd,hlg rCIKh i`oyd fhdackd lr ;sfí kï ta ms<sn`oj wjYH f;dr;=re tu iud.fuka ,nd .ekSug uu n,h mjrñ" ;jo ud ms<sn`o
f;dr;=re ´kEu Kh fok wdh;hlska ,nd.ekSugo Tn iud.ug wkque;sh foñ' fuu rCIKhg b,a¨ï lsÍug fmr isg mej;s" by; m%ldYhkays fkd±lajq fyda jika l, ;;a;ajhla
u; we;s jq frda.hla" ;=jd,hla" wk;=rla fyda urKhla iïnkaO ysñlï i`oyd iKi ,hs*a bkaIqjrkaia lïmeks mS't,a'iS' fj; j.lSula we;s fkdfõ'
I agree to inform SANASA life Insurance company PLC of any changes in my health or occupation between the date of proposal and the date of acceptance.
fuu fhdackd m;%h bÈßm;a l< Èkh iy th ms<s.kakd Èkh olajd w;r ld,h ;=, udf.a fi!LHh ;;a;ajh fyda /lshdfõ lsishï fjkila isÿjqjfyd;a ta ms<sn`oj iKi ,hs*a
bkaIqjrkaia lïmeks mS't,a'iS' fj; ±kaùug uu tl`. fjó'

Signature of the Insurer / rCIs;hdf.a w;aik Date / oskh

To be completed by an Authorised Ofiicer of the bank / Lending institution Loan No. Date of Birth
nexl=fõ $ wod, Kh fok wdh;kfha" n,h,;a ks,Odßhd úiska iïmQ¾K lsÍu i`oyd Kh wxlh rCIs;hdf.a Wmka Èkh DD / MM / YYYY

Home Business Loan Personal Loan Repayment Period (Months)

Loan Type ksjdi jHdmdr Kh fm!oa.,sl Kh (Excluding Grace period, if any) Grace Period (Months)
Kh j¾.h wdmiq f.ùfï ld, iSudj ^udi& iyk ld, iSudj ^udi&
Car Loan Education Loan Other Loan
r: jdyk Kh wOHdmk Kh fjk;a Kh ^iyk ld,h rys;j&

Loan Amount (Rs.) Interest Rate (%) Period of Fixed Rate

Kh jákdlu ^re'& fmd<S m%;sY;h ^]& ia:djr .dia;= ld, iSudj

I certify that the satisfactory evidence of age proof is seen by me and date of birth of birth given in the proposal form is accurate.
fhdackd m;%fhys i`oyka Wmka Èkh" i;H f,i ±lSfï§ i;=gqodhl uÜgñka ikd: l< yels nj fuhska iy;sl lrñ' ;jo" wjYH lreKq wkdjrKh lsÍfï jeo.;alu rCIs;hdg
meyeÈ,s l< nj;a" w;aik ud bÈßmsg fhÿ nj;a iy;sl lrñ

N I C No. (Life to be assured)

cd'ye' wxlh ^rCIs;hdf.a&

Birth Certificate No.

Wmamekak iy;sl wxlh
Signature of the Authorized Officer / n,h,;a ks,Odß w;aik
(Certified with Rubber Stamp)
Other (to be Specified) ^ks, uqodj fhdod iy;sl l, hq;=hs&
fjk;a ^úia;r lrkak&

Date / Èkh