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TATA AIA LIFE INSURANCE COMPANY LIMITED

(Incorporated in India)

Application Form

(For Official Use only)

in India) Application Form (For Official Use only) 1. Life Insurance is a contract of utmost

1. Life Insurance is a contract of utmost good faith and the Proposer/Life Insured are required to reply to all questions in this form truthfully and completely. 2. You are required to fill up the requisite

nomination/appointee details wherever applicable.

from the payor then KYC documents will be required for both. 5.*eIA Number = Insurance Repository A/C Number. Company Ltd.

6.Cash should be deposited only with authorized cashier of Tata AIA Life Insurance

3.Tata AIA Life has disclosed in this form all the material facts which are relevant for this proposal/contract. 4. If policy owner/ proposer is different

4. If policy owner/ proposer is different A. 1. 2. 5. 7. 9. 10. 12. B.

A.

1.

2.

5.

7.

9.

10.

12.

B.

1.

2.

5.

7.

9.

10.

11.

13.

14.

PERSONAL DETAILS OF PROPOSED INSURED

a) Name : First Name Middle Name Surname b) Father’s Name : First Name Middle
a)
Name :
First Name
Middle Name
Surname
b)
Father’s Name :
First Name
Middle Name
Surname
Gender:
M
F
3. Date of Birth:
D
D
M
M
Y
Y
Y
Y
4. Marital Status : Single
Married
Widowed
Divorced
Maiden Name :
In case of married women
6.
Identity Type :
Identity Number:
(Passport No.)
Nationality :
8.
a) Address 1/ Village :
Address 2/PO:
Address 3/PS:
Landmark :
City :
District :
State :
PIN Code :
b) STD Code
Tel. No. :
Mobile :
E-mail :
a) Business Address :
City :
State:
PIN Code :
b)
Tel. No.:
STD Code
c)
Fax :
STD Code
d)
Occupation :
e)
Exact Nature of Daily Duties :
f ) Annual Income (in Rs.) :
Which is your dominant hand?: Left
Right
11. Correspondence Address : Residential
Business
PAN Card No.:

Type of address Proof submitted:

Business PAN Card No.: Type of address Proof submitted: (Please attach copy of PAN Card) PERSONAL

(Please attach copy of PAN Card)

PERSONAL DETAILS OF PROPOSER / APPLICANT (If other than PROPOSED INSURED. For child’s application, Proposer means original Policyholder/Payor)

a) Name : First Name Middle Name Surname b) Father’s Name : First Name Middle
a) Name :
First Name
Middle Name
Surname
b) Father’s Name :
First Name
Middle Name
Surname
Gender:
M
F
3. Date of Birth:
D
D
M
M
Y
Y
Y
Y
4. Marital Status : Single
Married
Widowed
Divorced
Maiden Name :
In case of married women
6.
Identity Type :
Indentity Number:
(Passport No.)
$
Nationality :
8.
a)
Current Address 1/ Village :
Address 2/PO:
Address 3/PS:
Landmark :
City :
District :
State :
PIN Code :
b)
Tel. No. :
STD Code
Mobile :
E-mail :
$
Permanent Residential Address :
Landmark:
City:
State:
Pin Code:
a)
Business Address :
City :
State:
PIN Code :
b)
Tel. No.:
STD Code
c)
Fax :
STD Code
d)
Occupation :

e)

Exact Nature of Daily Duties :

STD Code d) Occupation : e) Exact Nature of Daily Duties : f ) Annual Income

f ) Annual Income (in Rs.) :

Exact Nature of Daily Duties : f ) Annual Income (in Rs.) : Which is your

Which is your dominant hand?:

Type of address Proof submitted:

Relationship with Proposed Insured:

address Proof submitted: Relationship with Proposed Insured: Left Right 12. Correspondence Address : Residential Business

Left

Proof submitted: Relationship with Proposed Insured: Left Right 12. Correspondence Address : Residential Business For

Right

12. Correspondence Address :

Proposed Insured: Left Right 12. Correspondence Address : Residential Business For Child Application, Applicant means

Residential

Insured: Left Right 12. Correspondence Address : Residential Business For Child Application, Applicant means Original

Business

Left Right 12. Correspondence Address : Residential Business For Child Application, Applicant means Original

For Child Application, Applicant means Original Policyholder/Payor

g)

PAN Card No.

g) PAN Card No. (Please attach copy of PAN Card)

(Please attach copy of PAN Card)

c.

Address Proof : Voter's ID Card Others

Objective of Insurance: Risk

Telephone Electricity Bill Bill (Specify) Savings Others Hindi Others (Specify): Email Phone
Telephone
Electricity
Bill
Bill
(Specify)
Savings
Others
Hindi
Others
(Specify):
Email
Phone

d. Are you a Politically exposed person?

Yes

Email Phone d. Are you a Politically exposed person? Yes No (If yes please provide details)

No

Phone d. Are you a Politically exposed person? Yes No (If yes please provide details) (Specify):

(If yes please provide details)

(Specify):

16.

17.

18.

$ If either of the current or permanent address field is left blank/ incomplete, then the address provided in either field will be considered relevant to the blank/ incomplete field as well.

Preferred language: English

Preferred Contact Mode: Postal

C. PAYOR INFORMATION (This section is to be completely filled in, when the payor is different from the Proposer/ Proposed Insured for the policy)

1. Title:

Mr.

Ms.the Proposer/ Proposed Insured for the policy) 1. Title: Mr. Mrs. Other (Specify): 2. Name: 3.

Proposer/ Proposed Insured for the policy) 1. Title: Mr. Ms. Mrs. Other (Specify): 2. Name: 3.

Mrs.

OtherProposed Insured for the policy) 1. Title: Mr. Ms. Mrs. (Specify): 2. Name: 3. Maiden Name:

Insured for the policy) 1. Title: Mr. Ms. Mrs. Other (Specify): 2. Name: 3. Maiden Name:

(Specify):

for the policy) 1. Title: Mr. Ms. Mrs. Other (Specify): 2. Name: 3. Maiden Name: (Female

2. Name:

3. Maiden Name:

Mr. Ms. Mrs. Other (Specify): 2. Name: 3. Maiden Name: (Female Lives only) 4. Gender &
Mr. Ms. Mrs. Other (Specify): 2. Name: 3. Maiden Name: (Female Lives only) 4. Gender &

(Female Lives only)

4. Gender & Date of Birth:

5. Nationality: Resident Indian

# Other than resident Indian please mention current country of residence

Male

Female D D M M Y Y Y Y  

Female

D

D

M

M

Y

Y

Y

Y

 

NRI

NRI PIO Foreign National*

PIO

Foreign National*

NRI PIO Foreign National*

# Country of Residence

NRI PIO Foreign National* # Country of Residence ( * Specify Nationality) 6. $ Current Residential

( * Specify Nationality)

National* # Country of Residence ( * Specify Nationality) 6. $ Current Residential Address: Landmark: City:

6.

$ Current Residential Address:

Landmark:

City:

6. $ Current Residential Address: Landmark: City: 7. State: Pin Code: $ Permanent Residential Address:
6. $ Current Residential Address: Landmark: City: 7. State: Pin Code: $ Permanent Residential Address:
6. $ Current Residential Address: Landmark: City: 7. State: Pin Code: $ Permanent Residential Address:

7.

State:

Pin Code:

Residential Address: Landmark: City: 7. State: Pin Code: $ Permanent Residential Address: Landmark: 8. 9. 10.
Residential Address: Landmark: City: 7. State: Pin Code: $ Permanent Residential Address: Landmark: 8. 9. 10.

$ Permanent Residential Address:

Landmark:

State: Pin Code: $ Permanent Residential Address: Landmark: 8. 9. 10. 11. City: State: Pin Code:
State: Pin Code: $ Permanent Residential Address: Landmark: 8. 9. 10. 11. City: State: Pin Code:

8.

9.

10.

11.

City:

State:

Pin Code:

Address: Landmark: 8. 9. 10. 11. City: State: Pin Code: Tel. ( R) No.: Tel. (
Address: Landmark: 8. 9. 10. 11. City: State: Pin Code: Tel. ( R) No.: Tel. (
Address: Landmark: 8. 9. 10. 11. City: State: Pin Code: Tel. ( R) No.: Tel. (

Tel. ( R) No.:

Tel. ( O) No.:

Mobile :

E-mail:

Tel. ( R) No.: Tel. ( O) No.: Mobile : E-mail: Relationship with Proposed Insured: Student
Tel. ( R) No.: Tel. ( O) No.: Mobile : E-mail: Relationship with Proposed Insured: Student

Relationship with Proposed Insured:

Student Housewife Retired
Student
Housewife
Retired
with Proposed Insured: Student Housewife Retired Occupation Class : Salaried Occupation Type :Public Ltd Self

Occupation Class : Salaried

Occupation Type :Public Ltd

Self Employed  

Self Employed

 

Pvt Ltd

ProfessionalPvt Ltd Proprietary Others (Specify)

Pvt Ltd Professional Proprietary Others (Specify)

Proprietary

Pvt Ltd Professional Proprietary Others (Specify)

Others

Pvt Ltd Professional Proprietary Others (Specify)

(Specify)

(including income from all sources)

Others (Specify) (including income from all sources) ( please attach a copy of PAN CARD) 13.

( please attach a copy of PAN CARD)

13.

14.

15.

16.

17.

Identity Proof : Passport PAN Card Voter's ID Others (Specify) Income Proof : ITR P&
Identity Proof : Passport
PAN Card
Voter's ID
Others
(Specify)
Income Proof : ITR
P& L account
CA Certificate
Others
(Specify)
Address Proof : Voter's ID Card
Telephone Bill
Electricity Bill
Others
(Specify)
**
Are you a Politically exposed person ?
Y
N
If yes please provide details
Have you ever been convicted of any criminal proceedings under any court of law in India or abroad?
Y
N

18.

If yes, please give details

PREVIOUS POLICY DETAILS (Details of Life Insurance/Health/Personal Accident Policies held/applied with Tata AIA Life or other companies in the capacity of Payor)

Tata AIA Life or other companies in the capacity of Payor) Company Name Basic Sum Assured

Company Name

Basic Sum Assured

Annual Premium

** “Politically Exposed Persons” are individuals entrusted with prominent public functions in a foreign country, e.g. Heads of State or of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations, important political party officials.The definition is not intended to cover middle ranking or more junior individuals in the foregoing categories”

D. BANK DETAILS (For all policy related payments made by the company)

Name

Branch

Account No.

E. DETAILS OF NOMINEE (Applicable only if Proposed insured and Applicant/ Proposer/ Policyholder is the same person)

Name (underline Surname/Family Name & expand any initials in the following sequence : Surname/Family Name, First Name, Middle Name)

Relationship

Age

Identity type & number

with Insured

12.

Annual Income : Rs.

12. Annual Income : Rs. per annum 13. PAN Card No.:

per annum

13. PAN Card No.:

F. DETAILS OF CONTINGENT POLICYHOLDER (For applications where insured is a child. An adult to become Policyholder in the event of the death of the original Policyholder).

Name

Relationship

Age

Identity type & number

Signature of Contingent Policyholder

with Insured

G. DETAILS OF APPOINTEE (Applicable only in cases where the nominee is below 18 years)

 

Name

Relationship

Age

Identity type

Signature of Appointee

with Insured

& number

H. INSURANCE APPLIED FOR

Basic Plan

Amount of Insurance (in Rs.)

Additional Benefits

 

I. FREQUENCY OF PREMIUM

J. TO BE COMPLETED BY INSURED IN ALL CASES ( and by Applicant/ Proposer, where Payor Benefit has been selected)

 

Insured

Applicant/

1. Are you now a member of any military force, engaged or are considering engaging in any hazardous sports or events (e.g. motor racing, climbing, scuba diving, etc.) or flying in any aerial device other than as a fare paying passenger on a regularly scheduled airline or travel overseas other than for vacation or holiday?

Proposer

Yes

No

Yes

No

2. Have you EVER had an application for life, accident, medical or health related refused, withdrawn, postponed or offered with restricted benefits or with an increased premium, or made any claim under any such policy of insurance? If answer to any of the questions above (1 or 2) is “Yes”, Please Provide details.

under any such policy of insurance? If answer to any of the questions above (1 or
under any such policy of insurance? If answer to any of the questions above (1 or
under any such policy of insurance? If answer to any of the questions above (1 or
under any such policy of insurance? If answer to any of the questions above (1 or

3. Do your have any existing insurance and/or concurrent application for insurance on your life? If “Yes”, please provide details. Indicate (I) for Insured or (A) for Applicant.

for insurance on your life? If “Yes”, please provide details. Indicate (I) for Insured or (A)
for insurance on your life? If “Yes”, please provide details. Indicate (I) for Insured or (A)
for insurance on your life? If “Yes”, please provide details. Indicate (I) for Insured or (A)
for insurance on your life? If “Yes”, please provide details. Indicate (I) for Insured or (A)

Name of Company

 

Sum Assured

Annual

Date of

 

Life

Critical Illness

Accident

Hospital

Premium

Issue

Critical Illness Accident Hospital Premium Issue K. HEALTH DETAILS OF INSURED Insured Applicant/ Proposer 1.

K. HEALTH DETAILS OF INSURED

Insured

Applicant/ Proposer

1. Height

a)

   

cm/feet

 

cm/feet

 

b)

Weight

kg/lb.

kg/lb.

c)

Has there been any change in your weight in the last 12 months ?

Yes

c) Has there been any change in your weight in the last 12 months ? Yes

No

c) Has there been any change in your weight in the last 12 months ? Yes

Yes

c) Has there been any change in your weight in the last 12 months ? Yes

No

c) Has there been any change in your weight in the last 12 months ? Yes
 

If “Yes”, please state amount change and cause if known.

Amount change :

 

Amount change :

 
 

Cause :

 

Cause :

 

2.

Do you smoke or other wise use tobacco product or have done so in the last 12 months?

Yes

 

No

   

Yes

 

No

   

If ‘Yes’. please state type and quantity consumed daily (average).

Type :

 

Type :

 

If ‘you’ have stopped smoking, please state date and reason.

Quantity :

 

Quantity :

 

3.

Do you drink alcohol?

Yes

 

No

   

Yes

 

No

   

If ’Yes’ please state type and quantity consumed per week (average).

Type (wine/spirit/beer):

Type (wine/spirit/beer):

If you have stopped consuming alcohol, please state date and reason

Quantity :

 

Quantity :

 
L. (contd.) Insured Applicant/ Proposer 4. Have you EVER HAD any of the following :
L.
(contd.)
Insured
Applicant/
Proposer
4.
Have you EVER HAD any of the following :
Yes
No
Yes
No
a)
Stroke, epilepsy, fits, recurrent headache, paralysis, faints or any other disease or disorder of the brain, spinal
cord or nerves?
b)
Depression, anxiety, schizophrenia or any other mental or nervous disorder?
c)
Diabetes, thyroid disorder or any other hormone disorder?
d)
Ear discharge, impaired sight, hearing or speech of any other disorder of ear, eye, nose or throat?
e)
Asthma, pneumonia, tuberculosis, emphysema, coughing up blood, persistent cough or any other disorder of the
chest or lungs?
f )
High blood pressure, palpitations, chest pain, raised cholesterol, heart attach or any other disorder of the heart or
blood vessels?
g)
Hepatitis (including hepatitis B carrier), liver disorder, gall bladder disorder, ulcer, bleeding from the stomach of bowel,
hemorrhoids or any other disorder of the digestive tract?
h)
Kidney or bladder disorder, urine abnormality or genital organ disorder?
i)
Cancer, tumor, cyst or growth of any kind?
j)
Anaemia, hemophilia, leukemia or any other blood disorder?
k)
Back or neck complaint, arthritis, gout, physical disability or other disorder of the bones, joints or muscles?
l)
Any illness that has caused you to be absent from work for a continuous period of 7 days or more?
5.
a)
Have you been infected with HIV (Human Immunodeficiency Virus), been diagnosed as having HIV antibodies or suffered
from an AIDS-related condition?
b)
Have you or your spouse received medical advice, testing or treatment in connection with sexually transmitted disease
or HIV infection or suffered from prolonged weight loss, diarrhoea, enlarged glands or unusual skin lesion or been
advised to abstain from donating blood?
6.
In the last 5 years have you consulted a doctor or any other medical facility for investigation or diagnostic tests (such as X-ray,
ultrasound, CT scan, biopsy, ECG, Blood or urine etc.)?
7.
Have you had any other illness, injury, operation or abnormality not mentioned under any question above which is recurrent
or has symptoms persisting for more than 7 days?
8.
Do you have any symptoms or condition for which you intend to attend a doctor in the future?
9.
Female Life Assured Only
a) Are you now pregnant? If ‘Yes’, please state expected delivery date.
Date :
D
D
M
M
Y
Y
Y
Y
b) Have you ever suffered from any complication during a previous pregnancy or delivery?
c) Have you suffered from any disorder of the breast or reproductive organs including abnormal smear test(s) and
irregular menses?
If answer to any of the questions above in STEP J (Questions 4 to 9) is “Yes”, please give full details (Diagnosis, Dates, Investigations, Results, Treatment
& Current Condition), noting the question number and indicated whether the answer related to Insured (I) or Applicant (A)
Question No.
Insured
Applicant/
10. Has either of your natural parents or any siblings died due to or suffered from cancer, heart disease, stroke, high blood
pressure, diabetes, kidney disease, mental disorder or depression, tuberculosis or polycystic kidney or other hereditary
Proposer
Yes
No
Yes
No
disease before the age of 65? If “Yes”, please provide details (type of cancer if applicable):
Y
Relationship
Type of Illness
Age at Diagnosis
Current Age
Age at Death
(if deceased)
Relative of
Relative of
(if living)
Insured
Applicant/
Proposer
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
11. Name and Address of your physician (western medical practitioner). Please provide registration
number, date, reason & result of last consultation.
Insured’s Doctor:
Applicant/Proposer’s
Doctor :
12. Please back date my application to :
D
D
M
M
Y
Y
Y
Y
Not applicable for juvenile application and term plans.
Y Not applicable for juvenile application and term plans. You have to disclose in this application

You have to disclose in this application ALL material facts which shall form the basis of our contract, otherwise the policy issued may be void or voidable. If you are in doubt whether a fact is material,please disclose it. Declaration & Authorisation: I/We hereby declare and agree that (a) I/We have read the application or the same was interpreted to me/us, and the answers entered in the application are mine/ours;(b) I/We hereby certify,on behalf of myself/ourselves and behalf of any person who may have or claim any interest in the said Policy,that each of the above answers is full, complete and true and I/We understand that Tata AIA Life Insurance Company Ltd.(hereafter called "the Company") believing them to be such, will rely and act on them,otherwise the proposed application may be void;(c) such application shall not be considered as effected by reason of any money paid,or settlement made in payment of or on account of any premium,until this application is received by the Company during the life time of the Insured and is finally approved by an authorized officer of the Company; (d) if my/our application be accepted by the Company, the Incontestability and Suicide Provision thereof shall have effect from the approval date of my/our application. Furthermore,I hereby irrevocably authorise (a) any organisation,institution,or individual that has any record of knowledge of my/the Insured's health and medical history or

AIA For more details on risk factors, terms and conditions please read sales brochure carefully
AIA For more details on risk factors, terms and conditions please read sales brochure carefully
AIA
AIA

For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale