TataAIA/NB/DM/67.

Defence Questionnaire
(To include Armed Services, Paramilitary services, police and other special forces)

Name of Proposed Insured: ............................................................................................................................

Policy no.: ....................................................................................... Dated:................................................

1) Which branch of Armed services are you in? Please select appropriate option from below

a) Army
b) Navy
c) Airforce
d) Paramilitary forces (eg. ITBP, BSF, CISF, Coastal Guards, SSB, CRPF)
e) State police forces including Railway Police
f) Special forces (eg. RAF, Black Cat commando, NSG, SPG, COBRA, Anti Terrorist Squad etc)
e) Others (kindly specify)
........................................................................................................................................................
......................................................................................................................................................

2) Current Rank & Designation

........................................................................................................................................................

3) Where is your current location of posting?

..........................................................................................................................................................

4) Nature of your job/role: (please select appropriate option)

Administrative Combat Non-combat

5) Are you engaged in any hazardous activities, e.g. aviation, diving, parachuting, bomb disposal or
special service groups? If so, please give details and length of service.
...........................................................................................................................................................

6) Are you currently serving in or are you under orders to proceed to any troubled area, or around
border areas of India?
............................................................................................................................................................

7) Do you handle weapons or explosives? If Yes, provide the details.

..............................................................................................................................................................

Tata AIA Life Insurance Company Limited

.(IRDA Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/240
TataAIA/NB/DM/67.1
I declare that the answers I have given are, to the best of my knowledge, true and I have not withheld any
material information that may influence the assessment of acceptance of this proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to disclose any
material fact known to me may invalidate the contract.

Signature of Proposed insured:______________________ Date:____________________

Signature of Applicant:______________________ Date:____________________

(If applicant is different from the proposed insured)

VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.

I__________________ holding ______________(ID card type) with number __________(ID card

number) hereby declare that I have explained the contents of this declaration to the Proposed
Insured/Applicant in ________________ language and that the Proposed Insured/Applicant has affixed
his/her signature/thumb impression after fully understanding the contents thereof.

________________________________ _____________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature

Tata AIA Life Insurance Company Limited

.(IRDA Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/240