DECLARATION OF GOOD HEALTH:

I hereby declare that:

1. I am in good health and have never suffered or currently suffering from or received treatment or
investigated or awaiting medical or surgical treatment for: (a) High blood pressure,
high Cholesterol, Chest Pain or heart attack or any other heart disease (b) Cancer, tumor, growth, pre-
cancerous or cyst of any kind (c) Stroke, paralysis in any form, Epilepsy,
Cerebrovascular Disease, any psychiatric/mental disorder including any genetic disease, disorder of
brain/nervous system or any kind of physical disabilities (d) Asthma,
Tuberculosis, Chronic Obstructive Pulmonary Diseases, Parenchymal Lung Disease, Pulmonary
Embolism or other lung disorder (e) Diseases or disorder of muscles, bones,
spine or joints including arthritis or anemia or any blood disorder or any endocrine disorder including
diabetes (f) Diseases of the kidney, genitourinary, any form of hepatitis or
liver disease or digestive system (Including stomach, pancreas, gall bladder, intestine, ulcers or colitis) (g)
Any lung or respiratory diseases (e.g. Asthma, Tuberculosis, COPD,
etc.) (h) Me or my spouse suffering from or been advised to undergo tests related to HIV/AIDS, Hepatitis
B, Hepatitis C (i) Any physical defect, deformity or disability*.
2. During the last 5 years, I have not undergone or have never been advised a) any major surgery or
hospitalization for more than one week or leave for more than 5 days on
medical grounds b) any investigations other than normal Health Check-ups and Insurance Medicals or
had adverse result for any blood tests, X-Rays, ECG, Stress Test,
Biopsies, Ultrasonography, CT Scan, MRI or 2D/3D echo.
3. I do not take part or intend to engage in any business, sport, occupation or in any adventurous
hobbies of hazardous nature.
4. I have never been medically advised treatment or advised to restrain from alcohol,
smoking/chewing tobacco or habit forming drugs such as heroin, cocaine, cannabis, Ganja
or LSD or any drug not prescribed by physician or have lost more than 10 kg in the last six months.
5. I do not have two or more of my first degree relatives in my immediate family members, whether
living or deceased, ever been diagnosed with Diabetes, Cancer, Stroke, Heart
ailment, any neurological disorder or any other hereditary/familial disorder before age 60.
6. I do not take any medication or have ever attended to a doctor for any conditions except for cough,
cold or similar minor conditions.
7. For Female Lives:
a. I have never undergone any investigations such as mammogram, Pap smear or any biopsy.
b. I have never suffered from any breast or gynecological disorder or pregnancy related complications.
8. I have never ever been declined, deferred, or accepted at special terms or had any covers reduced for
any life, health or accident insurance cover.
*Disability means inability to function normally, physically or mentally

DECLARATION
I further declare that the above statements are true and complete in every respect related to my health and
will form the basis of granting insurance cover to me, from Tata AIA
Life Insurance Company Ltd. I further hereby agree and give my consent to, the Policyholder for use of
the contents of this declaration by Tata AIA Life for examining and
processing any claim arising, in respect of the insurance cover that maybe provided to me under the
referred group policy.
I hereby confirm that my intent to participate in the above plan for the Policyholder's customers is purely
on a voluntary basis. I confirm and agree that the insurance cover, if
provided, will be governed by the provisions of the Insurance Act, 1938, the Policy Contract and the
Certificate of Insurance under which the cover will be offered to me.
I agree and understand that if I contract any of the above diseases between submitting this document and
the date of commencement of the cover, I shall not be covered under
the policy. I have also not withheld any material information or suppressed any fact. I undertake to notify
Tata AIA Life ('The Company') of any change in my state of health or
occupation or any decisions subsequent to the signing of this Enrolment Form and before the acceptance
of the risk by the Company. I hereby irrevocably authorize 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 Proposed Insured's health
status in relation to this application and any claim arising therefrom.
I/We hereby 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.

AUTHORIZATION OF CLAIM PAYMENT

I/We an Insured Member under the Group Master Policy bearing no.__<<GLPP000002
>>__________issued to the Master Policyholder_<<Tata Capital Financial Services Ltd>>_, hereby
authorize TATA AIA Life Insurance Company Ltd. to make payment of claim proceeds in favour of the
Master Policyholder to the extent of my outstanding loan amount under the Policy in the event of my
death and the balance if any to my Nominee under the Coverage. If the Master Policyholder is other than
the above mentioned entities, the benefit amount would be directly paid to my Nominee under the
coverage. I request the Company to settle the claim proceeds under the Policy as per this Authorization.

Section 41 of the Insurance Act, 1938 states:

(1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person
to take 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 maybe allowed in accordance with the published prospectuses or tables of
the insurer:
(2) Any person making default in complying with the provisions of this section shall be liable for a
penalty which may extend to ten lakh rupees.

Section 45 of the Insurance Act, 1938 states: I hereby declare, in case of fraud or misrepresentation by
me, the Certificate of Insurance shall be cancelled immediately by paying the
surrender value, subject to the fraud or misrepresentation being established by the insurer in accordance
with Section 45 of the Insurance Act, 1938 (As amended from time to time).
The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above contract. Please refer
to Section 45 either on our website or contact our intermediary or visit the
nearest branch for the full text.