DEFENSE QUESTIONNAIRE
(Questions to be filled by life to be assured)
Full name of life to be assured
Proposal number /Application number
1. Branch of Service
Army Navy Air Force Coast Guard
2. Rank & details of typical duties involved:
3. State your current posting. Is there any immediate possibility of you being posted to any troubled areas? Please state
location(s), likely length of posting(s), and details of duties involved.
4. Do you handle any explosives or engage in mines or bomb disposal? If yes, provide complete details.
5. Do you take part in:
i) Diving Yes No
ii) Para trooping Yes No
iii) Parachuting Yes No
iv) Commando activities
If any of the above is answered yes, then please mention
No. of Jumps: ______________ per annum
Max Depth: _______________meter
Location: ______________________
6. Do you fly any type of aircraft as part of your duties as a Pilot or as a Crew Member?
If yes, then mention the following:
a. The type of aircraft (make, model name and number)
b. Number of hours as a: pilot____________ passenger __________
c. Who owns the aircraft and does the owner hold an Air Operator's Certificate?
d. Who maintains the aircraft?
COMP/DOC/Jun/2021/286/6122
e. Where do you intend to fly? i.e. starting points and destinations
f. Have you ever had an accident while performing the above duties? Yes No
(If yes, please give full details)
I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information
that may influence the assessment or acceptance of this application.
I agree that this form will constitute part of my application for life assurance and that failure to disclose any material fact known to
me may invalidate the contract.
Place: __________________
__________________________________________ __________________________________________
Date: ___________________
Signature of the Life to be Assured / Proposer Signature of the Medical Examiner / Code No.