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TATA AIA LIFE INSURANCE COMPANY LIMITED

(Incorporated in India)
Payor

Application Form
(For Official Use only)

Important Note: 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.
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. 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 from the payor then KYC documents will be required for both. 5. *eIA Number = Insurance Repository A/C Number. 6. Cash should be deposited only with authorized cashier of Tata AIA Life Insurance Company Ltd.

Life Insurance Application Form : Rural Application No. : Policy No.: Agent/Specified Person/ Broker Name:

Urban

Medical

Non-Medical

Office Code: Sub Office Code: *eIA No.: Customer ID : Agent/Specified Person/ Broker Code :

I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository. PLEASE WRITE IN BLOCK LETTERS USING BLUE / BLACK INK. PLEASE USE TO INDICATE CHOICE. IN BOXES A. PERSONAL DETAILS OF PROPOSED INSURED 1. a) Name : b) Fathers Name : 2. Gender: M F 5. Maiden Name : 7. Nationality : Address 2/PO: Address 3/PS: City : b) Tel. No. : 9. a) Business Address : City : b) Tel. No.: STD Code Right c) Fax : e) Exact Nature of Daily Duties : 10. Which is your dominant hand?: Left 12. Type of address Proof submitted: 1. a) Name : b) Fathers Name : 2. Gender: M F 5. Maiden Name : 7. Nationality : Address 2/PO: Address 3/PS: City : b) Tel. No. : 9.
$

First Name First Name 3. Date of Birth: D D M M Y Y Y Y In case of married women 6. Identity Type : 8. a) Address 1/ Village :

Middle Name Middle Name 4. Marital Status : Single Married Widowed Identity Number:

Surname Surname Divorced (Passport No.)

Landmark : District : STD Code Mobile : State: STD Code d) Occupation : Business PAN Card No.:
(Please attach copy of PAN Card)

State : E-mail :

PIN Code :

PIN Code : f ) Annual Income (in Rs.) :

11. Correspondence Address : Residential

B. PERSONAL DETAILS OF PROPOSER / APPLICANT (If other than PROPOSED INSURED. For childs application, Proposer means original Policyholder/Payor) First Name First Name 3. Date of Birth: D D M M Y Y Y Y In case of married women
$

Middle Name Middle Name 4. Marital Status : Single Married Widowed 6. Identity Type : 8. a) Current Address 1/ Village : Landmark : Indentity Number:

Surname Surname Divorced (Passport No.)

District : STD Code Mobile :

State : E-mail :

PIN Code :

Permanent Residential Address :

Landmark: City: State: Pin Code: 10. a) Business Address : City : b) Tel. No.: g) PAN Card No. 11. Which is your dominant hand?: 13. Type of address Proof submitted: 14. Relationship with Proposed Insured: For Child Application, Applicant means Original Policyholder/Payor Left Right STD Code c) Fax : e) Exact Nature of Daily Duties : State: STD Code d) Occupation : f ) Annual Income (in Rs.) :
(Please attach copy of PAN Card)

PIN Code :

12. Correspondence Address :

Residential

Business

15. Are you the Payor of this Policy ? Yes a. Identity Proof : Passport Others c. Address Proof : Voter's ID Card Others 16. Objective of Insurance: Risk 17. Preferred language: English 18. Preferred Contact Mode: Postal
$

/No

If Yes, Please provide the details as below. (If Payor is other than the proposed insured/proposer, please fill in Step C ) b. Income Proof: ITR P&L account CA Certificate Others (Specify)

PAN Card (Specify) Telephone Bill


(Specify)

Voter's ID

Electricity Bill Others

d. Are you a Politically exposed person?


(If yes please provide details)

Yes

No

Savings Hindi Email Others Phone

(Specify):_______________

(Specify):_______________

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. 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: 2. Name: 3. Maiden Name: (Female Lives only)
4. Gender & Date of Birth:
#

Mr.

Ms.

Mrs.

Other

(Specify):

Male
#

Female NRI

D D M M Y Y Y Y

5. Nationality: Resident Indian


Other than resident Indian please mention current country of residence
$

PIO

Foreign National*
(* Specify Nationality)

Country of Residence

6.

Current Residential Address: City: State: Pin Code:

Landmark:

7.

Permanent Residential Address: City: State: Pin Code:

Landmark:

8. Tel. ( R) No.: Mobile : 9. Relationship with Proposed Insured: 10. Occupation Class : Salaried 11. Occupation Type :Public Ltd 12. Annual Income : Rs.
(including income from all sources)

Tel. ( O) No.: E-mail: Self Employed Pvt Ltd Student Housewife Proprietary 13. PAN Card No.: Others Others Electricity Bill (Specify) (Specify) Others (Specify)
N

Retired Others (Specify)


( please attach a copy of PAN CARD)

Professional per annum

13. Identity Proof : Passport 14. Income Proof : ITR

PAN Card

Voter's ID CA Certificate
N

P& L account

15. Address Proof : Voter's ID Card

Telephone Bill

16. Are you a Politically exposed person**? Y If yes, please give details

If yes please provide details

17. Have you ever been convicted of any criminal proceedings under any court of law in India or abroad? Y

18. 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) 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 with Insured Age Identity type & number

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 with Insured Age Identity type & number Signature of Contingent Policyholder

G. DETAILS OF APPOINTEE (Applicable only in cases where the nominee is below 18 years) Name Relationship with Insured Age Identity type & number Signature of Appointee

H. INSURANCE APPLIED FOR Basic Plan Amount of Insurance (in Rs.)

Additional Benefits

I. FREQUENCY OF PREMIUM Frequency of Premium : Premium Rs.


^

Annual +Service Tax Rs.


^

Semi-annual

Quarterly = Total Payment Rs.

Monthly For months initial deposit.

Service tax is applicable as per governing laws and the same shall be borne by the policyholder. Tata AIA Life Insurance Company Limited reserves the right to recover from the Policyholder, any levies and duties (including service tax), as imposed by the government from time to time. Kindly refer to the Sales Illustration for exact premium rates.

1. Please draw cheque/s favouring Tata AIA Life Insurance Company Ltd. Only. Do not issue blank cheque/s. 2. Please ask your agent for a Debit Authorisation Form for deduction of subsequent premiums through Credit Card/Bank Account. 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 Proposer racing, climbing, scuba diving, etc.) or flying in any aerial device other than as a fare paying passenger on a regularly scheduled airline Yes No Yes No or travel overseas other than for vacation or holiday? 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. 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. Name of Company Sum Assured Annual Date of Life Critical Illness Accident Hospital Premium Issue

K. HEALTH DETAILS OF INSURED 1. a) Height b) Weight c) Has there been any change in your weight in the last 12 months ? If Yes, please state amount change and cause if known. 2. Do you smoke or other wise use tobacco product or have done so in the last 12 months? If Yes. please state type and quantity consumed daily (average). If you have stopped smoking, please state date and reason. 3. Do you drink alcohol? If Yes please state type and quantity consumed per week (average). If you have stopped consuming alcohol, please state date and reason Yes Cause : Yes Type : Quantity : Yes Quantity :

Insured cm/feet kg/lb. No

Applicant/ Proposer cm/feet kg/lb. Yes Cause : No Amount change : Yes Type : Quantity : No

Amount change : No

No

Yes Quantity :

No

Type (wine/spirit/beer):

Type (wine/spirit/beer):

L. (contd.) 4. Have you EVER HAD any of the following : 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) j) l) Cancer, tumor, cyst or growth of any kind? Anaemia, hemophilia, leukemia or any other blood disorder? Any illness that has caused you to be absent from work for a continuous period of 7 days or more?

Insured Applicant/ Proposer Yes No Yes No

k) Back or neck complaint, arthritis, gout, physical disability or other disorder of the bones, joints or muscles?

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. 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 Yes No Applicant/ Proposer Yes No Date : D D M M Y Y Y Y

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 Y disease before the age of 65? If Yes, please provide details (type of cancer if applicable): Relationship Type of Illness Age at Diagnosis Current Age (if living) Age at Death (if deceased)

Relative of Relative of Insured Applicant/ Proposer Yes Yes Yes No No No Yes Yes Yes No No No

11. Name and Address of your physician (western medical practitioner). Please provide registration number, date, reason & result of last consultation.

Insureds Doctor:

Applicant/Proposers Doctor :

12. Please back date my application to : D D M M Y Y Y Y

Not applicable for juvenile application and term plans.

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

any treatment or advice that has been or may hereafter be consulted or other personal information to disclose to the Company such information. This authorisation shall bind my/the insured' successors and assigns and remain valid notwithstanding my/the Insured's death or incapacity in so far as legally possible; and (b) the Company or any of its approved medical examiners or laboratories to perform the necessary medical assessment and test to underwrite and evaluate my/the Insured's health status in relation to this application and any claim arising therefrom.These tests may include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, acquired immunodeficiency syndrome (AIDS), infection by any human immunodeficiency virus (HIV), immune disorder or the presence of medications, drugs, nicotine or their metabolites. A photocopy of this authorization shall be valid as the original. I also agree and undertake that a) if there is any material change in my circumstances, including but not limited to, changes in my health, employment, financial circumstances, arrest or being charged with a criminal offence, non-standard acceptance or rejection of a life insurance application, prior to the acceptance of the company of this application for insurance, I will immediately notify the company of such change in writing, and b) the company will take into account any such change in circumstances in deciding whether to reject or accept this application, and c) failure to notify the company in this manner shall, at the company's discretion, render this policy void and all moneys which shall have been paid in respect thereof shall stand forfeited to the company Tax Benefits: Tax benefits are available as per Income Tax act, 1961 and are subject to modifications made thereto from time to time.Tata AIA Life Insurance Company Ltd. does not assume the responsibility on tax implications mentioned anywhere in this document. Please consult your own tax consultant to know the tax benefit available to you. INSURANCE ACT 1938, Section 45: No policy of life insurance effected before the commencement of this act shall after expiry of two years from the date of commencement of the Insurance Act and no policy of life insurance effected after the coming into force of this act, shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal (application) for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making, that the statement was false or that it suppressed facts, which it was material to disclose. Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal (application). Cancellation right and refund of premium (Free Look Period): If you are not satisfied with the terms & conditions/ features of the policy, you have the right to cancel the Policy by providing written notice to the Company and receive the premiums after deducting (a) proportionate risk premium for the period on cover, (b) Stamp duty and medical examination costs which have been incurred for issuing the Policy. Such notice must be signed by you and received directly by the Company within 15 days from the date of receipt of the policy document. The said period of 15 days shall stand extended to 30 days, if the policy is sourced through distance marketing mode. For Unit Linked Life Insurance Products, you would receive the refund of the premiums invested into the funds at Unit Price as at the date of cancellation along with the charges paid, post deductions mentioned as per points (a) and (b) above. Anti Money Laundering Declaration: I hereby declare that: 1.The premium paid or would be paid has been derived from legally declared and assessed sources of income.2. I understand that the company has the right to peruse my financial profile and also agree that the company has right to cancel the insurance contract incase I have been found guilty of any of the provisions of any law, directly or indirectly, having relation to the laws governing prevention of money laundering in the country, by any competent court of law. Commencement of cover: I understand that the cover applied for under this application will commence after approval of my application and receipt of the required premium by the Company. INSURANCE ACT 1938, Section 41: Prohibition of Rebates. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees. Assignment: Assignee or transferee is the person, in whose name the policy has been assigned or transferred. Assignment and Transfer of insurance policy shall be governed by Sec 38 of Insurance Act, 1938 and as per rules and guidelines of IRDA as amended from time to time. Nomination: Nominee is the person to whom the money secured by the policy shall be paid in the event of death of the life to be assured and shall give valid discharge to the insurer. Transfer or assignment of policy made in accordance with Sec 38 of Insurance Act, shall automatically cancel a nomination. Nomination by Policy holder of insurance policy shall be governed by Sec 39 of Insurance Act, 1938 and as per rules and guidelines of IRDA as amended from time to time.

"I, the undersigned confirm that I have verified photocopies of the proofs submitted along with this application form against the originals and certify the same to be true copy.

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

Tata AIA Life Insurance Company Ltd. (Regn. No. 110) Registered & Corporate Office: Delphi- B Wing, 2nd Floor. Orchard Avenue, Hiranandani Business Park, Powai, Mumbai 400 076
For complete details please contact our Insurance advisor or visit Tata AIA Lifes nearest branch office or call our toll free number 1-800-11-9966 (facility available from MTNL and BSNL lines) and 1-860-266-9966 (facility available from all moblle and landlines wherein local charges would apply) or write to us at customercare@tataaia.com Visit us at: www.tataaia.com or SMS LIFE to 58888.

L&C/Advt/2012/Jun/079

AIA

PRAF019 NL

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