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JSC " “TBC Bank” Loan Linked Life Insurance Questionnaire
Hello, You have received a loan linked life insurance application that includes the personal and medical information you provided to the insurance representative during the telephone interview.
In order to review the notification, please follow the following steps:
1. Video verification
2. Confirm the notification or request change
You can use one of the following documents for video verification:
JSC " “TBC Bank” Loan Linked Life Insurance Questionnaire
You have received a loan linked life insurance application that includes the personal and medical information you provided to the insurance representative during the telephone interview. You have received a loan linked life insurance application that includes the personal and medical information you provided to the insurance representative during the telephone interview. You have received a loan linked
life insurance application that includes the personal and medical information you provided to the insurance representative during the telephone interview.
You have no application to confirm
General Information
First Name
Last Name
Personal ID
Date of Birth
Gender
Marital Status
Phone Number
Email Address
Citizenship
Actual Address
Country 1
City
Have you been insured with life insurance coverage before?
Insurance type
Insurance limit
Information about Loan
loan 1
Amount of Loan
Period of Loan
Loan inception Date
Employment Details
Employer / Company
Working Address
City
Country
Date of Hire
Position
Annual Salary
Number of hours worked per week
Short description of job
Text text Text text Text text Text text Text text Text text Text text
text text
Aviation Activity Details
Including aerobatics, air racing, competitions, exhibition flying, fixed wing, helicopters, record attempts, stunt flying and passengers (except as fare paying on a commercial aircraft)
What is the main purpose of your aviation activities?
Which aviation licence do you currently have?
Aircraft and fling times:
Which type of aircraft (make, model, number) do you usually fly?
What is the aircraft weight?
Number of hours flown to date and average per year to date
Total number of hours flown
Number of flying hours planned per year
Please give full details of any past or intended participation in any form of aerobatics, exhibitions,
prototype testing, record attempts, air-racing or stunt flying?
Please give details, including destination and frequency of any flights outside of your country of
residence
Merchant Marine Activity Details
Does your occupation involve going to sea (or is it likely to do so in the future)?
If, yes, which of the following types of vessels do you work on?
What percentage of your duties are of a manual or physical nature?
Have you had any accidents or illnesses associated with your duties?
Winter Sport Activity Details
What kind of winter sports do you perform?
Kindly specify the frequency of practising the sport? (eg daily, weekly, monthly…)
Where do you generally practise such sports? (eg: mountain area, region, country)
Do you participate in national or international competitions?
If yes, do you receive prize money sponsoring, PR, prize money, private donations and other supporting benefits by national sports, fund or any other financial support)?
How much (in percentage) of your overall income can be attributed to performing such sports?
How much (in percentage) of your overall income can be attributed to performing such sports?
If yes, please provide complete details (with medical report attached, if any):
Travel History Information
Anticipated travel itinerary for the next 12 months
Travel 1
Destination
Frequency
Duration
Purpose of trip
Residence and Travel Details
Please provide details of your current residency and your residency status including information of length of stay by visa etc, if appropriate.
Please provide details of your previous residence and travel during the last 5 years (excluding holidays of less than 4 weeks):
Visit 1
Dates of stay
Country and region of residence
Reason for visiting
Frequency (number of trips per year)
Duration of each stay
Please provide details of your future residence and travel intentions during the next 5 years (excluding holidays of less than 4 weeks):
Visit 1
Dates of stay
Country and region of residence
Reason for visiting
Frequency (number of trips per year)
Duration of each stay
Please provide a brief description of your occupational duties and/ or any other activities you will participate in whilst travelling or residing abroad
Do you expect to spend the majority of your time in major / large cities?
If NO, please provide the name of the town/ region and details of your likely
accommodation, availability of medical facilities and your internal travel arrangements (e.g. light aircraft, boat etc.)
Please give details of any medical treatment or surgery you have received whilst resident
overseas
Please provide any additional information on your residence and travel which you feel may be helpful in processing your application.
Medical History
Weight (kg)
Height (cm)
1) Within the past 10 years, have you been treated, diagnosed, tested, hospitalized, or
recommended for treatment for any of the following?
1) Within the past 10 years, have you been treated, diagnosed, tested, hospitalized, or
recommended for treatment for any of the following?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1A) Seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system?
1A) Seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1B) Mental retardation; any mental, behavioural, emotional or eating disorder; anxiety, depression, neurosis or psychosis; psychotherapy; psychological or any form of counseling or therapy?
1B) Mental retardation; any mental, behavioural, emotional or eating disorder; anxiety, depression, neurosis or psychosis; psychotherapy; psychological or any form of counseling or therapy?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1C) High blood pressure; heart attack, stroke, chest pain or palpitations, murmur, varicose veins, blood clot, anemia or any other blood, heart, or circulatory disorder or condition?
1C) High blood pressure; heart attack, stroke, chest pain or palpitations, murmur, varicose veins, blood clot, anemia or any other blood, heart, or circulatory disorder or condition?
Pressure reading
Date recorded
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1D) Asthma, emphysema, bronchitis, sinusitis, pneumonia, allerg ies, apnea or any breathing difficulty, lung or respiratory disease, disorder or condition?
1D) Asthma, emphysema, bronchitis, sinusitis, pneumonia, allerg ies, apnea or any breathing difficulty, lung or respiratory disease, disorder or condition?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1E) Colitis; chronic diarrhea, or intestinal problems; hernia; ulcer of the stomach or duodenum; hemorrhoids or rectal disorder; hepatitis or liver disorder; gallbladder, pancreas, esophagus, or any other digestive disorder or condition?
1E) Colitis; chronic diarrhea, or intestinal problems; hernia; ulcer of the stomach or duodenum; hemorrhoids or rectal disorder; hepatitis or liver disorder; gallbladder, pancreas, esophagus, or any other digestive disorder or condition?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1F) Cancer, tumor, growth, cyst, enlarged lymph nodes; psoriasis, keratosis, lesions of the skin or mouth or any other skin disorder?
1F) Cancer, tumor, growth, cyst, enlarged lymph nodes; psoriasis, keratosis, lesions of the skin or mouth or any other skin disorder?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1G) Disease or disorder of the breast; kidney; kidney stones; bladder; prostate; abnormal PSA, or any other urinary disorder or infection?
1G) Disease or disorder of the breast; kidney; kidney stones; bladder; prostate; abnormal PSA, or any other urinary disorder or infection?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1H) Disease or disorder of the genital or reproductive system; herpes, any sexually transmitted disease; endometriosis, or abnormal pap smear?
1H) Disease or disorder of the genital or reproductive system; herpes, any sexually transmitted disease; endometriosis, or abnormal pap smear?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1I) Been treated for infertility; taken any medication, or advised to seek treatment, medication, diagnostic tests or surgery for infertility?
1I) Been treated for infertility; taken any medication, or advised to seek treatment, medication, diagnostic tests or surgery for infertility?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1J) Arthritis; rheumatism; gout; TMJ (temporomandibular joint syndrome); any injury to or disease or disorder of the spine, back, jaw, bones, muscles, or joints; joint replacement?
1J) Arthritis; rheumatism; gout; TMJ (temporomandibular joint syndrome); any injury to or disease or disorder of the spine, back, jaw, bones, muscles, or joints; joint replacement?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1K) Pituitary, adrenal, or thyroid disorder; lupus; diabetes?
1K) Pituitary, adrenal, or thyroid disorder; lupus; diabetes?
Type
Blood sugar reading ate recorded
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1L) Cataracts; glaucoma; or any eye disorder; hearing loss; or any ear, nose, or throat disorder?
1L) Cataracts; glaucoma; or any eye disorder; hearing loss; or any ear, nose, or throat disorder?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1M) Alcoholism; alcohol, drug or substance abuse or dependency?
1M) Alcoholism; alcohol, drug or substance abuse or dependency?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
1N) Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV Positive, or other immune disorders?
1N) Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV Positive, or other immune disorders?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
2) Have you been advised to have a surgical procedure, hospitalization or undergo testing that has not
yet been completed?
2) Have you been advised to have a surgical procedure, hospitalization or undergo testing that has not
yet been completed?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
3) Are you currently pregnant?
3A) If yes, is there a history of complications with previous pregnancies or are complications
anticipated with this pregnancy?
3) Are you currently pregnant?
3A) If yes, is there a history of complications with previous pregnancies or are complications
anticipated with this pregnancy?
3B) Is this pregnancy the result of infertility treatment?
3) Are you currently pregnant?
3A) If yes, is there a history of complications with previous pregnancies or are complications
anticipated with this pregnancy?
3B) Is this pregnancy the result of infertility treatment?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
4) Have you gained or lost more than 12 kilos or 25 pounds during the last 12 months?
4) Have you gained or lost more than 12 kilos or 25 pounds during the last 12 months?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
5) Have you ever been declined, postponed, rated or limited for Life, Health or Accident Insurance?
6) Have you been hospitalized in the last 10 years for any reason?
6) Have you been hospitalized in the last 10 years for any reason?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
7) Have you consulted or been advised to consult a medical practitioner, or do you suffer from any significant physical impairment, deformity sickness, or injury other than revealed in questions above?
7) Have you consulted or been advised to consult a medical practitioner, or do you suffer from any significant physical impairment, deformity sickness, or injury other than revealed in questions above?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
8) Do you engage in any profession, sport, or hobby that could be considered hazardous?
9) Do you receive any disability pension or work accident pension?
9) Do you receive any disability pension or work accident pension?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
10) In the last 3 months have you tested positive for COVID-19?
10) In the last 3 months have you tested positive for COVID-19?
If so, when was this?
Condition/ Diagnosis
Treatment (Surgeries/Medications)
Treatment Dates From/To
Name, Location and Phone Number of physician or medical institution
11) In the last 1 month have you:
11) In the last 1 month have you:
11) In the last 1 month have you:
11) In the last 1 month have you:
11) In the last 1 month have you:
11) In the last 1 month have you:
11) In the last 1 month have you:
I confirm that, I fully recovered from all COVID-19 symptoms without complications and returned to normal physical function and activities
Medications
Medication Name 1
Dosage
Frequency
Consumption rule
Medical Practitioner
Name, Surname
E-mail Address
Phone Number
Acknowledgements and Authorizations
I, the Undersigned Hereby
1. Declare that the foregoing answers to the best of my knowledge and belief are true and accurate and are offered as an inducement to grant insurance.
2. Declare that I am currently actively at work and mentally and physically capable of conducting the regular duties of my employment and have not been absent from work for more than 10 consecutive days in the preceding twelve months due to illness.
3. Agree that there shall be no insurance until the Insurer has approved this application.
4. Authorize any medical professional, hospital, clinic, other medical or medically related facility, governmental agency, or other person or firm to provide the Insurer or their authorized representative information, including copies of records, concerning advice, care or treatment provided to me, including without limitation, information relating to mental illness or use of drugs or alcohol.
5. Understand that such information will be used by the Insurer for the purpose of evaluating my application for insurance or by Insurer representatives involved in evaluating, determining or administering claims for insurance benefits.
გამოგვყევი
2023 TSC Insurance
