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TATA AIA LIFE INSURANCE COMPANY LIMITED photograph of photograph of

<<COMMON PROPOSAL FORM OR Product name with product tag line>> the the Life
Kindly fill the form in CAPITAL and only in blue or black Proposer/Annuita Assured/Second
nt/Primary ary Annuitant
(For Official Use only)
Annuitant
Proposal Number: ____________________________ Branch Code: ___________________ Channel: ________________________
Campaign Code: ____________________________________________________________ Sub Office Code: _________________
RM CAMS Code: _______________________________________ POS/Agent/Broker/Specified Person/Employee: ____________________________________________________
Code__________________________________ Contact Details ___________________________ License No. & Validity Details__________________________________________
Customer Relationship No.: _______________________________ (For Bancassurance Channel) PAN No. |__|__|__|__|__|__|__|__|__|__|
IMPORTANT GUIDELINES: 1) IN UNIT-LINKED INSURANCE POLICIES (ULIPs), THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE
POLICYHOLDER. 2) Insurance is a contract of utmost good faith between the Insurer and the Insured. The Proposer and the Life to be Assured are required to
disclose all facts in response to the questions in this application form. 3) Any cancellation/alteration is to be signed by Proposer/Life to be assured as applicable.
4) KYC documents will be required for all the parties to the contract.
I. GENERIC DETAILS
Is this policy self-proposed? [ ] Yes [ ] No If No, please answer the following details Type of Proposer [ ] Individual [ ] Entity
Relation with Life Assured _________________ Type of Proposal [ ] Employer Employee [ ] Keyman [ ] Partnership [ ]Trust [ ] HUF [ ] MWPA
II. ELECTRONIC INSURANCE ACCOUNT (eIA) DETAILS OF THE PROPOSER/POLICYOWNER
[ ] If you have an e-Insurance Account (eIA) Number, please provide______________________
I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Tata AIA Life Insurance Company Ltd. In
[ ]Physical Format [ ] Electronic Format (Physical copy would be sent even if proposer opts for electronic format; however, in case proposer has e-Insurance
Account, only electronic copy of the Insurance Policy will be provided)
[ ] I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Insurance Repository in the Electronic
Format as and when applicable. Please select the name of the Insurance Repository.
[ ]NSDL Data Management Ltd [ ] CDSL Insurance Repository Ltd [ ] Karvy Insurance Repository Ltd [ ] CAMS Repository Services Ltd [ ] Other____________
III. PRODUCT DETAILS
Base Plan / Rider Unit Linked Life Insured Name Sum Policy Premium Premium Premium Return of
(Benefit Option) (Yes/No) Assured Term Paying (Rs.) Paying Mode Premium
Name (Rs.) (Years & Term (inclusive of option
Months) (Years & applicable
Months) taxes,
cesses &
levies)

Life Insured Details Benefit Payout Option details

Benefit
Base Plan / Rider (Benefit Income Income
Payout Lumpsum Income
option) Name Name DOB Gender Duratio Freque
Option (Rs.) p.a (Rs.)
n (yrs) ncy

Kindly DATE BACK my Application to DD/MM/YYYY 1. Allowed only as per product specifications 2. Allowed within the same financial year 3. In case of juvenile
(less than 1 year) back date is not allowed. 4. Date Back of policy is allowed only up to the official launch date of the product.

Tata AIA Vitality (Wellness Program, applicable only for specific product/riders): << Yes / No / Not Applicable>>
Utilization of Rewards during the Premium Payment Term (if ‘Wellness Program’ is opted): : [ ] Premium Discount [ ] Premium Cashback
FUND SELECTION DETAILS (To be filled for Unit Linked Products) a. Kindly mention the names of the fund chosen b. In case you opt for a specific Portfolio
Strategy (as available with individual products), kindly mention the Fund Names or other details as applicable c. Kindly fill in whole numbers in percentage only.
Decimals and Fractions not allowed.
Name of Fund % Allocation Portfolio Strategy
________________________________________________________________

OR Funds for the chosen Portfolio Strategy (If Applicable)

Debt oriented fund Equity oriented fund

Other Details(if applicable)_________________________

Please select Frequency of Cash Bonus Payout: [ ] Yearly [ ] Half yearly [ ] Quarterly [ ] Monthly
Please select mode of Cash Bonus Payout: [ ] Sub-Wallet [ ] % Paid-in Cash [ ] Premium Offset
Date of Cash Bonus Payout: if Special Date is chosen: dd/mm
PURCHASE PRICE & PLAN DETAILS FOR ANNUITY PLAN (APPLICABLE ONLY FOR ANNUITY PRODUCT)
PURCHASE PRICE / ANNUITY AMOUNT (Please tick any of the two choices)
[ ] Purchase Price/Annualised Premium __________________________or [ ] Annuity Amount ______________________________________________
Premium Payment Term: [ ] Premium Payment Mode: Single [ ] Annual [ ] Half-yearly [ ] Quarterly [ ] Monthly [ ]
Please select Frequency of Annuity Payout [ ] Yearly in arrears [ ] Half yearly in arrears [ ] Quarterly in arrears [ ] Monthly in arrears [ ] Yearly in
advance
Purchase Price/Premium Payment Details: [ ] Credit Card [ ] Cash [ ] Cheque [ ] Demand Draft
Amount:_________________________________________ Bank
Name:_____________________________________________________________________
Cheque/DD No.___________________________ Date: DD/MM/YYYY Bank Account
Number___________________________________________________
ANNUITY OPTION (Please tick annuity of your choice)
Would you like to opt for? [ ] Single Life [ ] Joint Life
[ ] Immediate Life Annuity
[ ] Immediate Life Annuity with Return of Purchase Price
[ ] Deferred Life Annuity (GA-I) with Return of Purchase Price
[ ] Deferred Life Annuity (GA-II) with Return of Purchase Price

Deferment period: [ ]

IV. PROPOSER / POLICYHOLDER / ANNUITANT/ PRIMARY ANNUITANT DETAILS (Please fill in details of Life Assured if same as Proposer)
1. Title [ ] Mr. [ ] Ms. [ ] Mrs. [ ] Dr. [ ] Others
2. Name First Middle Last
3. Father's Name /
First Last
Spouse Name
4. Mother’s Name First Last
5. Maiden Name
(For female lives First Last
only)
6. Gender/Date of
[ ] Male [ ] Female [ ] Transgender DD/MM/YYYY
Birth
7. Which is your
Dominant Hand?
(Question to be
[ ] Left [ ] Right
answered only if
ADDL Rider is
selected)
8. Marital Status [ ] Unmarried [ ] Married [ ] Divorced [ ] Separated [ ] Widow/Widower
9. Life Stage [ ] Youth [ ] Married [ ] Family with School going kids [ ] Family with college going kids [ ] Near retirement and retirement
10. Nationality (If
[ ] Resident Indian [ ] NRI [ ] OCI [ ] PIO [ ] Foreign National (Nationality) ___________________________
other than resident
Indian, Passport as
Country of Residence________________________________________ (If country of residence or nationality outside India then FATCA/
an age proof is
CRS-Self Certification Form to be mandatorily completed)
mandatory)
11. Residence for
Tax purposes in
[ ] Yes [ ] No (If ‘Yes’ then FATCA/ CRS-Self Certification Form to be mandatorily completed)
Jurisdiction(s)
outside India
12. Highest
Educational [ ] Post Graduate [ ] Graduate [ ] Diploma [ ] 12th [ ] 10th [ ] Illiterate [ ] Others _____________
Qualification
13. Current __________________________________________________________________________________________
Residence Landmark:_________________________________________ City: ____________________________________
Address State:________________________ Country: ______________________ Pin code:_____________________
14. Permanent __________________________________________________________________________________________
Address Landmark:_________________________________________ City: ____________________________________
State:________________________ Country: ______________________ Pin code:_____________________
15. Address for
[ ] Current [ ] Permanent
Communication
16. Telephone and Residence No.________ _______________Mobile No. __________
Email Details E-mail_____________________________________________________________________________________
17. Occupation [ ] Salaried [ ] Agriculture [ ] Housewife [ ] Retired [ ] Student [ ] Self Employed [ ] Business Owner [ ] Others
Class _____________________________
a. Name of
Organisation
/School / College _________________________________________________________________________________________________
b. Organisation
[ ] Govt [ ] Public Ltd [ ] Pvt. Ltd [ ] Partnership Firm [ ] Proprietorship Firm [ ] Others ______________
Type
c. Industry [ ] Financial [ ] Manufacturing [ ] Retail [ ] Infrastructure [ ] Mining [ ] Others _______________
d. Nature of Work [ ] Desk Job [ ] Heavy/Manual Labor [ ] Skilled Worker [ ] Agriculture [ ] Driver [ ] Jeweller [ ] Contractor
[ ]Crane Operator [ ] Machine Operator [ ] Armed Forces [ ] Mariner (Offshore/Onshore) [ ] Others ____________
e. Annual Income
(Rs.)
18. Income Proof _________________________________________________________________________________________________________
19. Identity Proof
(In case of
Passport & Driving [ ] Passport [ ] Driving License [ ] Expiry Date ________________
License please [ ] Voter's ID [ ] PAN Card [ ] NREGA Job Card [ ] Masked Aadhaar [ ] Others____________
mention expiry
date)
20. Address Proof
[ ] Passport [ ] Driving License [ ] Expiry Date ________________
for current
[ ] Voter's ID [ ] NREGA Job Card [ ] Masked Aadhaar [ ] Others________
address ()
21. Permanent
Account Number ( ___________________________ (kindly attach copy of Pan card) [ ] I Do not have PAN (kindly attach copy of Form 60 duly signed)
PAN ) :
22. CKYC No.
(If available) _________________________________________________________________________________________________________
23. Source of
Funds
24. Are you a Politically Exposed Person? [ ] Yes [ ] No (Definition of PEP: “PEP are individuals who are or have been entrusted with prominent public
functions, domestically/in an international organisation /in a foreign country. This would include individuals who have or have had positions of Heads of State or
of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations, important political party officials”.
“Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of
partnership. Close associates are individuals closely connected to a PEP, either socially or professionally”)
25. Area Census
______________________________________________ (Applicable for Micro Insurance Product only)
Code
26. Below Poverty
Line Card Holder [ ] Yes [ ] No (Applicable for Micro Insurance Product only)
(BPL)
V. LIFE ASSURED / SECONDARY ANNUITANT DETAILS (Please fill in this section only if Life Assured is different from Proposer)
1. Title [ ] Mr. [ ] Ms. [ ] Mrs. [ ] Dr. [ ] Others
2. Name First Middle Last
3. Maiden Name
(For female lives
only)
4. Gender/Date of [ ] Male [ ] Female [ ] Transgender DD/MM/YYYY
Birth
5. Relationship
With Primary
Annuitant ___________________________________________________________________________________
6. Which is your
Dominant Hand?
(Question to be
[ ] Left [ ] Right
answered only if
ADDL Rider is
selected)
7. Marital Status [ ] Unmarried [ ] Married [ ] Divorced [ ] Separated [ ] Widow/Widower
8. Life Stage [ ] Youth [ ] Married [ ] Family with School going kids [ ] Family with college going kids [ ] Near retirement and retirement
9. Nationality (If [ ] Resident Indian [ ] NRI [ ] OCI [ ] PIO [ ] Foreign National (Nationality) _______________
other than resident
Indian, Passport as Country of Residence________________________________________
an age proof is
mandatory)
Residence for Tax
purposes in
[ ] Yes [ ] No (If ‘Yes’ then FATCA/ CRS-Self Certification Form to be mandatorily completed)
Jurisdiction(s)
outside India
10. Highest [ ] Post Graduate [ ] Graduate [ ] Diploma [ ] 12th [ ] 10th [ ] Illiterate [ ] Others _____________
Educational
Qualification
11. Occupation [ ] Salaried [ ] [ ] Agriculture [ ] Housewife [ ] Retired [ ] Student [ ] Self Employed [ ] Business Owner
Class [ ] Others _____________________________
a) Name of
Organisation/
School/College ___________________________________________________________________________________________________
b) Organisation [ ] Govt [ ] Public Ltd [ ] Pvt Ltd [ ] Partnership Firm [ ] Proprietorship Firm [ ] Others ______________
Type
c) Industry [ ] Financial [ ] Manufacturing [ ] Retail [ ] Infrastructure [ ] Mining [ ] Others _______________
d) Nature of Work [ ] Desk Job [ ] Heavy/Manual Labor [ ] Skilled Worker [ ] Agriculture [ ] Driver [ ] Jeweller [ ] Contractor
[ ]Crane Operator [ ] Machine Operator [ ] Armed Forces [ ] Mariner (Offshore/Onshore) [ ] Others ____________
e) Annual Income
(Rs.)
12. Income Proof
13. Identity Proof
(In case of
Passport & Driving [ ] Passport [ ] Driving License [ ] Expiry Date ________________
License please [ ] Voter's ID [ ] PAN Card [ ] NREGA Job Card [ ] Masked Aadhaar [ ] Others____________
mention expiry
date)
14. Address Proof
[ ] Passport [ ] Driving License [ ] Expiry Date ________________
for current
[ ] Voter's ID [ ] NREGA Job Card [ ] Masked Aadhaar [ ] Others____________
address)
15. Permanent ___________________________ (kindly attach copy of Pan card) [ ] I Do not have PAN (kindly attach copy of Form 60 duly signed)
Account Number
( PAN ) :
16. Are you a Politically Exposed Person? [ ] Yes [ ] No (Definition of PEP: “PEP are individuals who are or have been entrusted with prominent public
functions, domestically/in an international organisation /in a foreign country. This would include individuals who have or have had positions of Heads of State or
of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations, important political party officials”.
“Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of
partnership. Close associates are individuals closely connected to a PEP, either socially or professionally”)
VI. HEALTH & LIFESTYLE DETAILS OF THE LIFE ASSURED (NOT APPLICABLE FOR MICRO INSURANCE PLAN)
1. Nature of Age proof (Non-standard age proof submission will attract extra premium)
[ ] Municipality Birth Certificate [ ] Passport [ ]PAN Card [ ] School/Education Certificate [ ] Others Kindly Specify_______________________
2. a) Height (cms or ft) b) Weight ( kg or lbs). ________ cms/ft _________ Kgs/lbs
PART A: LIFESTYLE DETAILS (NOT APPLICABLE FOR SAVINGS PLANS WITH BASIC SUM ASSURED OF UP TO Rs.20 LAKHS)
1. Are you employed in the Armed Forces, Paramilitary, Police Forces, Fire Brigade or any other similar occupation? [ ] Yes [ ] No
2. Is your occupation/your hobbies associated with any specific accident/health hazard or are dangerous in any way (e.g. working [ ] Yes [ ] No
with dangerous or corrosive chemicals, explosives, radiation, working underwater/underground or at height, working in mines, non-
commercial flying activities, diving, mountaineering, any form of motorbike/car racing etc.)?
3. Do you intend to live or travel outside India for more than 30 days for reason other than family vacation in next 6 months? [ ] Yes [ ] No
4. Have you ever been charge sheeted or convicted of any criminal proceedings or have any criminal case or charge pending [ ] Yes [ ] No
against you in any court of law in India or abroad? If Yes, please provide complete details.
5. Do you consume or have consumed any of the following? Please tick all relevant options and provide details [ ] Yes [ ] No
Substance Yes/ No Consumed Quantity/ Per Day for No. of years If stopped consumption,
Consumed As Tobacco & Per week for mention month and year in
Alcohol and Narcotics which last consumed
Tobacco [ ] Yes [ ] No Cigar/Cigare
tte/Beedi/Gu
tkha/Other
Nicotine
containing
substances
Alcohol [ ] Yes [ ] No Beer/Wine/H
ard
 Liquor/Count
ry Liquor
Any Narcotics [ ] Yes [ ] No Cocaine/Am
phetamines/
Marijuana/B
arbiturates/
Other
Stimulants
PART B: HEALTH & PERSONAL DETAILS (NOT APPLICABLE FOR SAVINGS PLANS WITH BASIC SUM ASSURED OF UP TO Rs.20 LAKHS)
1. Has any of your insurance application or reinstatement application on life, accident, medical or health, critical illness, or disability [ ] Yes [ ] No
ever been declined, postponed or accepted at extra premium or modified terms?
2. Did you have any loss or Gain of weight of 10 kgs or more in the last six months? [ ] Yes [ ] No
3. Do you have any physical deformity / handicap or congenital defect / abnormality? [ ] Yes [ ] No
4. Have you ever been advised to and / or have undergone any tests, investigations or surgery or had signs or symptoms of any [ ] Yes [ ] No
condition, aliment or injury and / or were advised treatment for or have been hospitalized for check-up or treatment other than minor
flu, cold or influenza?
5. Have you ever been diagnosed with or investigated for any of the following: [ ] Yes [ ] No
a. Cardio: High or Low Blood Pressure / Raised Cholesterol / Chest Pain / Palpitation / Rheumatic Fever / Heart Murmur / [ ] Yes [ ] No
Shortness of Breath / Heart Attack / Stroke / Any other heart condition
b. Hormonal: High Blood Sugar/ Diabetes / Thyroid or endocrine disorder / Sugar in Urine / Any other hormonal disorder [ ] Yes [ ] No
c. Respiratory: Asthma / Tuberculosis / chronic cough, chronic bronchitis, emphysema, pneumonia / Any other respiratory disorder [ ] Yes [ ] No
d. Blood/Cellular: Cancer / Tumor or malignant growth / Leukemia / Anemia / Enlarged lymph nodes/ Any blood disorder [ ] Yes [ ] No
e. Digestive/Regulatory: Recurrent indigestion / Gastritis / Stomach or Duodenal Ulcer / Hernia / Jaundice / Disorders of the liver / [ ] Yes [ ] No
Cirrhosis and Gastrointestinal System/ Any other disease
f. Mental/Psychiatric/Neurological ailment: Symptoms or ailment relating to Brain Depression / Anxiety/ Brain Disorder or [ ] Yes [ ] No
disease / Mental/ Psychiatric / Transient ischemic attack /Parkinson's disease / Multiple Sclerosis / Nervous disorder / Paralysis or
Paraplegia / Epilepsy / Any other mental or psychiatric ailment
g. Neural/Skeletal/Muscular: Musculoskeletal disorders such as Arthritis / Recurrent Back Pain / muscular dystrophies/ [ ] Yes [ ] No
musculoskeletal deformities/ Slipped disc or any other disorder of Spine, Joints, Limbs or Leprosy; / Disorders of Eye, Ear, Nose,
Throat including defective sight / Disorder of speech or hearing and discharge from ears / Any other disorder
h. Infectious/Contagious: Were you or your spouse ever tested for Hepatitis B or C, HIV /AIDS or any other Sexually Transmitted [ ] Yes [ ] No
Disease / Any other disorder
i. Genitourinary: Hydrocele / fistula / piles / symptoms or ailment relating to Kidney / Kidney Stones/ Prostate, Urinary System or [ ] Yes [ ] No
Reproductive System / Any other disorder
6. Have you had/ are having any other illness or impairment not mentioned above? [ ] Yes [ ] No
7. Are you presently in good health? [ ] Yes [ ] No
8. Has any of your family member (Parents and Siblings) ever been diagnosed with diabetes, Hypertension, Kidney Failure, Cancer, [ ] Yes [ ] No
Heart Attack or any Hereditary Disorder before the age of 60?
9. Have you ever been advised to undergo any surgery or treatment or laboratory investigations (stress ECG, echocardiogram, [ ] Yes [ ] No
angiography, MRI/CT scan etc.) by any doctor or specialist?
10. Have you been off work due to illness for a continuous period of 7 days and above during the last 5 years? [ ] Yes [ ] No
11. Female Life Questionnaire [ ] Yes [ ] No
a. Are you now Pregnant? If Yes, kindly state expected delivery date ________________ [ ] Yes [ ] No
b. Have you undergone any gynecological investigations for illness, internal checkups, breast checks such as mammogram or [ ] Yes [ ] No
biopsy?
c. Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, fallopian tubes, menstruation, [ ] Yes [ ] No
complications during pregnancy or child delivery or a sexually transmitted disease?
d. Have you suffered from any other disorder of the breast or reproductive organs, abnormal smear test(s) and irregular menses? [ ] Yes [ ] No

12. If answer to any of the question above is ‘yes’, kindly give full details noting the question number (attach relevant copies)
Question No.: Details:
13. Family Details (Mandatory if the life to insured is Juvenile/Student/Housewife)
Family Details Name Gender (Male/ Date of Birth Occupation Annual Income (Rs.) Insurance Details
Female/Transgender) (Existing /Applied for)
Father/Husband DD/MM/YYYY
First Child / Sibling DD/MM/YYYY
Second Child / Sibling DD/MM/YYYY
14.Family Details to be filled for Life Father Mother Brother Sister Spouse
Assured only
a. If Alive, Health Status
b. If Deceased, Cause of Death
c. Age at Death/Current Age
PART C: HEALTH DECLARATION OF LIFE ASSURED (FOR ALLSAVINGS PLANS WITH BASIC SUM ASSURED OF UP TO Rs.20 LAKHS)
Do you have any disorder of the heart or circulatory system, high blood pressure, stroke, asthma or other lung condition, cancer or tumor of any kind, diabetes, hepatitis or
liver condition, urinary or kidney disorder, depression, mental or psychiatric condition, epilepsy, HIV infection or a positive test to HIV, any disease of the brain or the nervous
system, blood disorder? Do you currently have, or received treatment for any medical conditions, disabilities? Do you suffer from any symptoms that have persisted for more
than seven days? Do you currently have, or have been admitted to a Hospital/Nursing Home for treatment or any symptoms, medical condition or disabilities? Have you ever
been absent from work due to illness or injury for a continuous period of more than 10 days during the last 03 years?
[ ] Yes [ ] No

VII. EXISTING INSURANCE DETAILS

Do you currently hold or have applied for Life Insurance/Pension/Health (Cancer/Cardiac/Critical Illness) /Personal Accident Policies? [Y] / [N]
If Yes, kindly provide details as below:
Life Assured Proposer (If Life Assured is Juvenile/Student/Housewife)
Basic
Type of Insurance Type of Insurance
Sum
(Life/ Health (Cancer/Cardiac/Critical (Life/ Health (Cancer/Cardiac/Critical Basic Sum Assured
Company Name Assur Company Name
Illness)/ Unit Linked /Pension/ Illness)/ Unit Linked /Pension/ Personal (Rs.)
ed Accident)
Personal Accident)
(Rs.)

VIII. NOMINEE DETAILS (Required only if Proposer & Life Assured are the same) /
PARTNER DETAILS (only if ‘Partner Care’ payout option has been opted )
Base Plan / Rider Name Date of Gender Relationship Percentage ( % )
(Benefit Option) Birth (Male/Female/ (Do not enter % in decimals
Name Transgender) & total % should be equal to
100)
First Middle Last
DD/MM/YY
YY
First Middle Last DD/MM/YY
YY
First Middle Last DD/MM/YY
YY
IX. APPOINTEE DETAILS (Required only if Nominee is less than 18 years of age)
Name Date of Gender Relationship
Birth (Male/Female/Tran
sgender)
First Middle Last DD/MM/YY
YY
X. PAYMENT DETAILS
Premium Payment Method: [ ] Cash [ ] Cheque [ ] Demand Draft [ ] Digital/Online [ ] Standing Instructions (Credit Card/Debit Card) [ ] Fund Transfer
[ ] Others ____________________________________
Name of Credit Card/Debit Card Holder: ___________________________ Credit Card/Debit Card Number
___________________________________________
Cheque/DD No. ____________________ Issuing Bank ________________ Branch ___________________ Amount __________________ Date:
DD/MM/YYYY

Premium# Rs.__________________ + Taxes, cesses & levies Rs._____________________= Total Payment Rs. ______________________ for _______months
initial deposit (To be filled for monthly mode only)

On the first policy/modal anniversary I would like to change the premium payment mode to ______________, subject to policy contract provisions. For
Annual/Monthly mode issued # policies mode change shall be accepted only on completion of first policy anniversary. #Premium is exclusive of applicable taxes,
cesses & levies. All Premiums are subject to applicable taxes, cesses & levies which will entirely be borne by the Policyholder and will always be paid by the
Policyholder along with the payment of Premium. If any imposition (tax or otherwise) is levied by any statutory or administrative body under the Policy, Tata AIA
Life Insurance Company Limited reserves the right to claim the same from the Policyholder. Alternatively, Tata AIA Life Insurance Company Limited has the right
to deduct the amount from the benefits payable by Us under the Policy. Cheque/DD should be drawn in favor of “Tata AIA Life Insurance Company Ltd. <Proposal
No>”. Do not issue blank cheque.
Renewal Payment Mode: [ ] Standing Instructions (Credit Card/Debit Card) [ ] Cash/Cheque/Online [ ] NACH [ ] Others ________________________
XI. Mandatory Bank Account Details: Please provide below bank details. Bank details provided should be in the name of Proposer. All policy payouts will be
made to the below mentioned bank account through electronic transfer (NEFT). Payout would be in accordance and subject to terms and conditions of the policy.
Bank
Bank Name and Account
Name of Account Holder Accou IFSC Code
Branch Type
nt No.
[ ] Current
[ ] Savings
[ ] NRO
[ ] NRE
Note: 1. Please provide a cancelled copy of your personalized cheque. If personalized cancelled cheque is not available, attach bank statement showing account
holder name, address and account number. 2. In case of Non-Credit to the given bank account with/without assigning any reason thereof or if the transaction is
delayed or not effected at all for any reason of incomplete information, Tata AIA Life Insurance Co Ltd will not be responsible. 3. Further, the Company reserves
the right to use any alternative payout option inspite of opting for Direct Credit option. 4. If Account type is NRE/NRO then FATCA/CRS-Self Certification Form
to be mandatorily completed.
XII. Waiting Period (applicable only for POS products except Immediate Annuity Products):
In case of death of the life insured during the first <<xx>> days from the date of commencement of risk, the claimant shall be entitled to the total premiums paid.
Waiting period shall not be applicable in case of death due to accident.
XIII. Authorized Representatives’ Details (Please fill if Proposer/Policyholder/ Annuitant/Primary Annuitant are Non-Individual Persons)
1. Title [ ] Mr. [ ] Ms. [ ] Mrs. [ ] Dr. [ ] Others
2. Name First Middle Last
3. Gender/Date of [ ] Male [ ] Female [ ] Transgender DD/MM/YYYY
Birth
4. Nationality (If [ ] Resident Indian [ ] NRI
other than resident
Indian, Passport as
an age proof is
mandatory)
5. Current __________________________________________________________________________________________
Residence Address Landmark:_________________________________________ City: ____________________________________
State:________________________ Country: ______________________ Pin code:_____________________
6. Permanent __________________________________________________________________________________________
Address Landmark:_________________________________________ City: ____________________________________
State:________________________ Country: ______________________ Pin code:_____________________
7. Identity Proof (In
case of Passport &
[ ] Passport [ ] Driving License [ ] Expiry Date ________________
Driving License
[ ] Voter's ID [ ] PAN Card [ ] NREGA Job Card [ ] Masked Aadhaar [ ] [ ] Others
please mention
expiry date)
8. Address Proof
[ ] Passport [ ] Driving License [ ] Expiry Date ________________
for current
[ ] Voter's ID [ ] PAN Card [ ] NREGA Job Card [ ] Masked Aadhaar [ ] [ ] Others
address)
9. Permanent ___________________________ (kindly attach copy of Pan card) [ ] I Do not have PAN (kindly attach copy of Form 60 duly signed)
Account Number (
PAN ) :
10. CKYC No.
(If available)
XIV. DECLARATION & CONSENT

• I hereby declare, on my behalf and on behalf of all persons proposed to be insured, 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 authorised to propose on behalf of these other persons (applicable where the
proposer and life insured are different).
• I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer
and that the policy will come into force only after full payment of the premium chargeable.
• I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has
been submitted but before communication of the risk acceptance by the company.
• I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be
insured/ proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/ proposer
and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of
underwriting the proposal and/or claim settlement.
• I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer (if any) for the sole purpose of
underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

• I confirm that I have understood the contents of this Proposal Form and I am submitting this Proposal Form with all the details which are true and correct. I have
not withheld any material information or suppressed any fact which are essential for issuance of the policy. I also hereby authorize the Company to ascertain all
the details from any third parties, as may be required for assessing the risk.

• I agree to undergo all medical tests as determined by the Company for obtaining the policy and I further understand that the Company reserves the right to
issue the policy if all the required criteria are met and in case of any fraud or misstatement being established, the insurer shall take action in accordance with
Section 45 of the Insurance Act, 1938 as amended time to time. I understand that the contract will be governed by the provisions of the Insurance Act, 1938 as
amended time to time, the IRDA Act, 1999 and the Regulations framed there under and that the contract will not commence until the Company's written acceptance
of this Proposal Form is received. In case of the life to be insured being a minor, I further declare and affirm that this proposal of insurance is for the benefit of
the life to be insured.

• Anti-Money Laundering Declaration: I hereby confirm that all premiums will be paid from bonafide sources and no premiums will be paid out of proceeds of
crime related to any of the offence listed in Prevention of Money Laundering Act, 2002. The Company has the right to peruse my financial profile and also agree
that the Company has right to cancel the insurance contract in case 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.

• I/We understand that in accordance with the IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, the insurer is permitted to share policyholder
information only with the statutory authorities. I permit/authorize the Company to collect, store, communicate and process information relating to the
Policy/Account and all transactions therein, by the Company and any of its affiliates or service providers wherever situated including sharing, transfer and
disclosure between them or with any entity or entities for the purpose of underwriting, policyholder servicing and claims; and to the authorities in and/or outside
India for compliance with any law or regulation whether domestic or foreign.
Date:_________________________

Place:________________________
Signature/Thumb impression of Proposer/Primary Annuitant/ Authorized Representative Signature/Thumb Impression of Life Assured/Secondary
Annuitant
I hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I undertake to inform you of any changes
therein, immediately in case any of the above information is found to be false or untrue or misstated, before issuance of the proposal. “I, the undersigned confirm
that I have verified photocopies of the proofs submitted along with this proposal form against the originals and certify the same to be true copy”.

- I declare and confirm that I have carried out necessary suitability analysis while advising this product to the proposer and that the product is suitable to the
proposer.

WHERE THE PROPOSAL FORM IS FILLED IN BY AGENT/INTERMEDAIRY/EMPLOYEE: I hereby declare that I have explained the contents of this proposal
to the Proposer/Annuitants in the language known to him/her and ensured that the contents have been fully understood by him/her. I have accurately recorded
the Proposer/ Annuitant’s responses to the information sought in the proposal form and I have read out the responses to the Proposer/Annuitants and he/she
has confirmed that they are correct

Signature of Agent/ Specified Person/ Broker/ Employee

IN CASE OF THUMB IMPRESSION OF PROPOSER/ANNUITANTS OR WHERE THE ANSWERS/SIGNATURE OF THE PROPOSER/ ANNUITANTS ARE IN
VERNACULAR.

Note: The below must be declared by someone other than advisor/employee of the company.
I, _______________________________________ (name) have explained the contents of this proposal to the
_________________________________________ (Proposer/Annuitants) in ____________________ (language) and ensured that the contents have been fully
understood by him/her. I have accurately recorded the Proposer/ Annuitant’s responses to the information sought in the proposal form and I have read out the
responses to the Proposer/Annuitants and he/she has confirmed that they are correct.

(Signature of the person making the declaration) Date:_______________________________

Place:______________________________

Address of the person making the declaration:_______________________________________________________________________________________

Declaration by Proposer/ Life Assured/ Annuitant:

I have understood the contents of this proposal explained to me in _________________________ language and confirm that the responses provided by me are
correct.

Signature/Thumb impression of Proposer/ Primary Annuitant Signature/Thumb Impression of the Life Assured/Secondary Annuitant
Date:__________________________________ Date:__________________________________
Place:_________________________________ Place:__________________________________

(Prohibition of Rebates) Section 41 - of the Insurance Act, 1938 as amended from time to time: 1. 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 or continuing
a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer

SECTION 45 OF THE INSURANCE ACT, 1938 STATES: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of
three years from the date of policy, i.e. from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date
of the rider to the policy, whichever is later. A policy of life insurance may be called in question at any time within three years from the date of issuance of the
policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds
and materials on which such decision is based. 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 adjusted on subsequent proof that the age of the life insured was
incorrectly stated in the proposal. For further details, please refer to the Insurance Act, as amended from time to time.

Disclaimers: IN CASE OF A ULIP POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER. Tata AIA Life
Insurance Company Limited is only the name of the Company and any contract bearing the prefix "Tata AIA Life" is only the name of the contract and does not
in any way indicate the quality of the contracts, its future prospects or returns. Premium paid in ULIP is subject to investment risks associated with capital markets
& the NAV of the units may go up or down based on the performance of the funds and factors influencing capital markets and the insured is responsible for his
decision. Past performance is not indicative of future results. For more details on risk factors, terms and conditions please read sales brochure carefully before
concluding a sale.

BEWARE OF SPURIOUS PHONE CALLS AND FICTITOUS/FRAUDULENT OFFERS! - IRDAI is not involved in activities like selling insurance
policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint.

L&C/Advt/____/__/_____
.……………………………………………………………………………………………………………………………………………………………………………………………………………………………..

ACKNOWLEDGEMENT
Tear away portion (To be handed over to the customer)
Proposal Number: ___________________
Dear Customer
We acknowledge receipt of your Cash/Cheque/DD for Rs.______________ by number ______________ dated ___ /___ /___ drawn on _______________ toward’
s Initial Deposit. We request you to kindly verify the details filled in the proposal form before signing the same. Please do insist on Official Receipt issued by Tata AIA
Life from your advisor within 2 working days from submission of this proposal form. In case you do not hear from us or do not receive your policy within 15/(4 days for
PoS)days from the date of submission of your proposal, please visit us at www.tataaia.com or call our helpline number 1860 266 9966 (local charges apply) or email
us at [email protected].
This is only acknowledgement slip and not the premium receipt.

____________ _____________ ___________________ ________________________

Agent Code Agent Name Signature of Agent Date of Acknowledgement
 Cancer Care Questionnaire (to be answered only if Multistage Cancer Care Benefit is opted)

1. Have you suffered from or been advised investigation/investigated or been treated for any form of Cancer, sarcoma, tumor, or pre- [ ] Yes [ ] No
cancerous conditions (few example but not exhaustive are Barrett's esophagus, atrophic gastritis, cervical dysplasia, leukoplakia)
2. Are you suffering from or ever suffered from, Hepatitis B, Hepatitis C, Liver disease due to alcohol, Barrett's Esophagus, Crohn's [ ] Yes [ ] No
Disease, Peptic Ulcer, Ulcerative Colitis ?
3. Have you suffered from or been investigated for any of the following in [ ] Yes [ ] No
a. Recurrent cough, hoarseness of voice, or difficulty in swallowing for a continuous period of 15 days?
b. Any persistent loss of blood or unusual discharge from any part of the body?
c. Weight loss more than 5kg within 6 months other than through a weight loss program?
d. Any ulceration, growth, nodule, cyst or lump in any part of the body?
4. Have you had abnormal findings in any of the listed investigations in the last 6 months (if applicable)- [ ] Yes [ ] No
[] Ultrasound [] Endoscopy/Colonoscopy [] CT Scan / MRI [] Biopsy [] PAP Smear [] Mammography
[] Blood test for cancer diagnosis (Tumor Marker)
5. Have any of your parents (below age 60 yrs), sisters or brothers suffered from any form of cancer? [ ] Yes [ ] No
6. Are you suffering from or ever suffered from HIV/AIDs, Chronic Glomerulonephritis, Chronic Kidney Disease, Polycystic Kidney [ ] Yes [ ] No
Disease, Anemia?
7. Are you suffering from or ever suffered from Fatty liver, Gastritis, Gastro-Esophageal Reflux? [ ] Yes [ ] No
8. Has your proposal for life insurance, accident, medical or health related insurance ever been declined, postponed, withdrawn or [ ] Yes [ ] No
accepted at extra premium
Cardiac Care Questionnaire (to be answered only if Multistage Cardiac Care Benefit is opted)
[ ] Yes [ ] No
1. Have you ever had, or been told that you have, or are you currently under investigation for any of the below:
a. Any Heart condition like coronary artery disease, valvular or congenital heart disease b. High blood pressure c. Stroke
d. High cholesterol/lipids e. Raised blood sugar/diabetes f. Abnormal findings in ECG, TMT, CXR, Echo, Angiography or any
other cardiac investigation
2. Have your suffered from or been investigated for any of the following in the past 12 months? [ ] Yes [ ] No
a. Chest pain b. Breathlessness c. Excessive fatigue d. Severe headaches e. Dizziness f. Syncope
3. Have any of your immediate family members been diagnosed with heart ailment, diabetes or stroke before the age of 65 years? [ ] Yes [ ] No
4. Have you ever been diagnosed with, treated/investigated for or advised to take treatment for cancer, kidney or liver disease, blood, [ ] Yes [ ] No
joint or skin disorder, stomach disorder, brain or lung disease, mental/neurological disorder, gynecological disorder, physical or
congenital deformity or HIV/AIDS?
5. Has any of your proposal for issuance or application for reinstatement for life, health or accident insurance ever been declined, [ ] Yes [ ] No
postponed, withdrawn, accepted at extra premium or subjected to any special terms?

…………………………………………………………………………………………………………………………………………………………………………………………………

1. Please carry valid Identity card to the medical examination center wherever applicable. 2. For cash payment, please visit our nearest Tata AIA Life branch. Please
do not handover cash to Agent. If handed over to the agent, the company will not be liable for any loss. 3. In case there is any change in the particulars given above
including Life Assured/Proposer's health and/or medical and/or financial and/or occupational status and/or being charged with and/or arrested for any criminal
offence after the date of proposal but before risk acceptance by the company; please inform the company. 4. Acceptance of premium does not constitute risk
commencement. 5. Risk commencement starts after the acceptance of risk by the company. 6. 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 including applicable taxes, cesses & levies, 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 by you or person authorized by you. The said period of 15 days shall stand extended to 30 days, if the policy sourced through distance marketing mode
which includes solicitation through any means of communication other than in person. For Unit Linked Life Insurance products, you would receive the non – allocated
premiums plus charges levied by cancellation of units plus fund value at the date of cancellation and after deducting the charges as mentioned in (a) & (b) above.

Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110 • CIN: U66010MH2000PLC128403). Registered & Corporate Office: 14th Floor, Tower A,
Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is
used by Tata AIA Life Insurance Company Ltd under a license. For any information including cancellation, claims and complaints, please contact our Insurance
Advisor/ Intermediary or visit Tata AIA Life’s nearest branch office or call 1- 860-266-9966 (local charges apply) or write to us at [email protected]. Visit
us at: www.tataaia.com.