TataAIA/NB/DM/68

ADDENDUM TO APPLICATION
(To be completed where the policy is desired to be financed through HUF funds)

Application Number: _________________

1. What is the object of this Assurance? ___________________________________________________

(Please see note below)

2. Please state the full name and address of the Karta of HUF : __________________________________

3. Please state the name and age of the present Name Age
members/Co-parcenars in the HUF :

Signature of the Insured*: _______________________ Date: _______________________

I agree to the issue of a Policy and payment of premium as proposed.

Signature of Karta (HUF): _______________________ Date: _______________________

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

Witness: Witness:

Signature _____________________ Signature _____________________

Full name ______________________ Full name ______________________

Occupation _______________________ Occupation _______________________

Address _______________________ Address _______________________

Note: If this policy is proposed for the benefit of the HUF so as to form a part of HUF assets and premiums
under the policy are to be paid from out of HUF funds, the policy will belong to the HUF and in consequence the
life assured will not be entitled to make an Assignment or Nomination under the Policy nor he/she will be
entitled to draw any loan thereunder or surrender the same.
*If Insured is a minor then Karta will sign on behalf of the minor Insured.

Tata AIA Life Insurance Company Limited

(IRDA of India. 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/244