Medical Declaration Form - New Joiners - 20th Feb'23

Name of the Candidate (Full name)
Position applied for

Location Date of birth
Important instructions:
a. Please fill all details in block letters

b. All the questions are mandatory
c. Please ensure information accuracy as this may impact your employability eligibility with the
organisation
d. The application will be considered invalid in the event of any untrue or incorrect statement,
misrepresentation, non-description or non-disclosure of any material fact, particularly the
Resume/ CV submitted along with supporting documents such as but not limited to proof of
employment, academic mark sheet, declaration etc. If you have any queries or are unsure of
any question, please seek assistance by writing to us at [email protected]
within 3 days of receiving this communication.
Sr. No. Question Answer Remark

Please provide following details- You may refer any of the online videos to know the
correct method of measurement
Weight (in kg)
1 Height (in cms)
Waist circumference (in cms)
Hip circumference (in cms)
Do you have a history of or were recently
diagnosed with conditions related to following body Yes/ No
system
Diabetes
High BP or any heart ailment
High cholesterol
Asthma or COPD
Thyroid
Bone and muscle disorder
Mental disorders such as but not limited to
depression, bipolar disorder, anxiety disorder,
2
alcohol use disorder, substance abuse, drug abuse
etc.
Learning disability
Immunological disorders: Allergy or any
autoimmune disease
Any blood disorder: Anaemia, Thalassemia,
Leukemia
Tuberculosis, Hepatitis
Cancer (any type)
Do you have any lump or abnormal growth in the
body or benign tumour
Any other disease
Do you have a history of or were recently
diagnosed with conditions related to following body Yes/ No
system
Cardiovascular system
3 Respiratory system
Gastrointestinal system
Neurological system
Any other body system
Did you undergo any medical/ surgical treatment in
4 the past or recently? If yes, please mention the
treatment type in the Remark section.
HIV
5 Have your undergone a HIV test ever
Have you been tested positive of HIV
Are you on any medication? If yes, pleas mention
6
the result/ medication details in the Remark section
Does any of your family members have any of the
7 above-mentioned medical conditions? If yes, please
mention the conditions in the Remark section
Are you a person with special needs? If yes, please
8 mention the medical condition in the Remark
column
Declaration:
I hereby declare, on my behalf that the above statements, answers and/ or particulars given by me
are true and complete in all respects to the best of my knowledge and that I am authorized to propose
on behalf of these other persons. I understand that the information provided by me will form the basis
of my employment eligibility and consideration with Aditya Birla Capital & it’s subsidiary. I further
declare that I will notify in writing any change occurring in the occupation or general health at all times
(event during my employment with the organisation, if offered).
I declare that I consent to the company seeking medical information from any doctor or hospital
who/which at any time has attended on me or from any past or present employer concerning anything
which affects my physical or mental health.
I authorize the company to share information pertaining to my application including the medical
records for the sole purpose of recruitment and with any Governmental and/or Regulatory authority.
Name
Location Date
Signature
Miscellaneous Information Declaration
A. Do you have an advisor code? Yes/No

If yes, do provide your AMFI / Advisor Code:
B. Mention Total Years of Experience:
C. Do you have any relatives working with the Aditya Birla Group? Yes/No
If yes, kindly provide the following info:
S No. Employee Code Name Designation Department Company

1
Name
Signature
Only for ABSLI:-
“ I, Mr/Ms._______________________ (full name) is aware that, During my employment stint

with Aditya Birla Sun Life Insurance Company Limited (‘ABSLI’), I cannot hold any active advisor,
distributor and/or broker code from any of the business entities of Aditya Birla Capital. I am also
aware that I cannot have advisor code with any other Insurance Companies during my
employment with ABSLI. Deviation to the above by retaining and/or doing business under the
advisor, distributor and/or broker code of any other companies will be considered as ‘Conflict of
Interest’ under the provisions of organisation’s ‘Code of Conduct’ and related policies, besides
violation of IRDA rules and regulations. I am aware that, I need to surrender any such Advisor,
Distributor and/or Broker code of any organisation within 90 days of joining ABSLI, failing which
ABSLI reserves the right to initiate appropriate action including termination of employment, without
further notice to me.”
Signature of Candidate
Date

Medical Declaration Form - New Joiners - 20th Feb'23

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Name of the Candidate (Full name)

Position applied for

a. Please fill all details in block letters

Sr. No. Question Answer Remark

A. Do you have an advisor code? Yes/No

B. Mention Total Years of Experience:

If yes, kindly provide the following info:

S No. Employee Code Name Designation Department Company

Only for ABSLI:-

“ I, Mr/Ms._______________________ (full name) is aware that, During my employment stint

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