We are committed to giving a

Fikar-Free Life for you and your family.

Enabling your dreams

and inspiring you to
live a happier and
healthier life.

Insurance Policy Kit for

Deepika Singh

Verify your personal details and ensure your kit contains:

1/46
 ,  ,

ND15 C237338956 BD 243/2146 BROK Term_EIA C-70

Deepika Singh
117/658K BLOCK GEETA NAGAR KANPUR January 30, 2025
GEETA NAGAR
KANPUR NAGAR 208025
UTTAR PRADESH INDIA
M- 6386990070

Tata AIA Sampoorna Raksha Promise (UIN: 110N176V02)

Non-linked, Non-participating, Pure Risk, Individual life Insurance Product
1. Part A

Dear Deepika Singh,

Thank you for choosing us for your insurance needs. Tata AIA Life is committed to give you world-class products and professional service.

We take great pleasure in presenting your Policy Document. You may also refer to the Customer Information Sheet enclosed herewith which
provides basic information about your policy. Please check your personal details and the policy provisions carefully. Should you have any queries,
please contact your agent or contact us at the address mentioned below. You can also reach us via email at customercare@tataaia.com or call our
helpline number 1860-266-9966 (Call charges apply).

In order to provide your better services, We request you to intimate us in the event of any change in the address of the Policyholder or the
nominee.

If you are not satisfied with the terms & conditions, you have the right to cancel the policy by providing a written notice to the Company stating
objections/reasons and receive the refund of all premiums paid without interest after deducting proportionate risk premium, stamp duty
and medical examination cost along with applicable taxes, cesses and levies which have been incurred for issuing the policy. Such notice must be
received directly by the Company within 30 days from the date of receipt of the policy document by you or person authorized by you whether the
policy is sourced electronically or otherwise.

<<You are eligible for Health Management Services which is a Value-Added Service feature under the product, as detailed under Clause V (i) of
the Part C>>

At Tata AIA Life we believe that life inspires us to think ahead. Our insurance solutions are therefore designed to be a step ahead, thus giving you
an advantage to adapt to tomorrow’s changes, starting today.

We look forward to a long and cherished relationship with you.

Best wishes,

For and on behalf of

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Tata AIA Life Insurance Company Limited
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Venkatachalam H xwgo7X•Lq9•fcp9syds/nwLU§eLB.h¥
MD and CEO
Authorised Signatory ©1¡¡¡1©-a‰‰•A]}9q]•¡¥}¥y]¡mU

Scan the QR to download e-policy document

CLICK HERE TO READ THE TERMS AND CONDITIONS

Policy Servicing Branch : 1st Floor,SCO-18-19,Sector-14, NrPayalCinema,Gurugram,Haryana - 122002

Tata AIA Life Insurance Company Ltd (IRDA of India Regn.No.110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.

#HarWaqtKeLiyeTaiyaar Go to Table of Contents 2/46

 "Stamp duty of Rs. 1980 is paid as provided under Article 47(C)/(D) of Indian Stamp Act, 1899 and included in Consolidated
Stamp duty paid to the Government of Maharashtra Treasury vide order of Addl. Controller of Stamps, Mumbai at General Stamp
office, Fort, Mumbai – 400001 vide his order No. LOA/CSD/65/2024-25/4876 / Date 16/10/2024 / Validity period Dt.
17/10/2024 to Dt. 31/10/2025"

(Signature)
Proper Officer

Tata AIA Sampoorna Raksha Promise (UIN: 110N176V02)

Non-linked, Non-participating, Pure Risk, Individual life Insurance Product

INSURED Deepika Singh

POLICY NUMBER C237338956

Policy Terms and Conditions and Privileges within referred to

This Policy is the evidence of the contract between Tata AIA Life Insurance Company Limited and the Policyholder referred to below.

PREAMBLE

Tata AIA Life Insurance Company Limited (“the Company”) a leading Company in Life Insurance Sector, having received a
Proposal form and other related documents with Declaration thereto and initial premium from the Policyholder hereby issues
Tata AIA Sampoorna Raksha Promise (UIN: 110N176V02) Non-Linked, Non-Participating, Pure Risk, Individual Life Insurance
Product. Company basis the assurance by this Policy; do agree in consideration and subject to Policy conditions to pay the
benefits under the Policy on happening of an Insured event, while the Policy is in force. The basic insurance plan provided by
this Policy, with its amount of coverage and Premium is specified on the Policy Schedule. Entitlement to benefits, conditions for
payment and other policy details are also set out inside. This Policy is subject to term and conditions mentioned herein below
along with endorsements if any.

Signature valid
Signed by: Venkatachalam H
Date:
Location:

This is a system generated document requiring no physical signature.

#HarWaqtKeLiyeTaiyaar Go to Table of Contents 3/46

 TABLE OF CONTENTS
Section Description Page No.

Policy schedule Detailed overview of your registered policy 5

List of the beneficial features that comprise

Key feature document 7
your plan

Range of customer-centric services offered by

Service options 9
Tata AIA Life Insurance

A pre-investment, agreed-upon form that

Proposal Form 23
proposes the details of your policy

An illustrative way of presenting year-wise

Benefit illustration premiums payable and benefits under the 23
policy

Acknowledgement of the first premium

First premium receipt 46
payment

#HarWaqtKeLiyeTaiyaar Go to Table of Contents 4/46

 POLICY SCHEDULE
Tata AIA Sampoorna Raksha Promise (UIN: 110N176V02)
Non-linked, Non-participating, Pure Risk, Individual life Insurance Product
THIS SCHEDULE MUST BE READ WITH THE POLICY DOCUMENT AND IS PART
OF THE LIFE INSURANCE

Policy Number: C237338956

Policyholder Details Policyholder/ Life Assured (First Life) Life Assured (Second Life)
Name Deepika Singh N/A
117/658K BLOCK GEETA NAGAR KANPUR N/A
GEETA NAGAR N/A
KANPUR NAGAR N/A
Address UTTAR PRADESH N/A
208025 N/A
N/A
N/A
Client ID 392155249 N/A
Date of Birth 11/02/1989 N/A
Age at entry 35 years N/A
Age Admitted Y N/A
Gender Female N/A

Date of Date of Date of Annualised Policy

Plan Basic Sum Life Stage
Base Plan/Rider Name commencement of commencement Maturity of Premium (Excl. Term
Option Assured (Rs.) Option
policy of Risk Policy taxes) (Rs.) (Years)
Tata AIA Sampoorna
Raksha Promise Life 99,00,000.00 29/01/2025 29/01/2025 29/01/2060 14,290.00 No 35 years
(UIN: 110N176V02)

Due Date of Total Modal

Mode of Premium Premium Applicable Premium
Premium Last Premium
Base Plan/Rider Name Premium Paying Term (Excl. taxes) taxes, cesses & (Incl. taxes)
Due Date (s) Premium (Incl. taxes)
Payment (Years) (Rs.) levies (Rs.) (Rs.)
Payment (Rs.)
Tata AIA Sampoorna Raksha
Promise Monthly 35 28/02/2025 29/12/2059 1,136.00 204.00 1,340 1,340.00
(UIN: 110N176V02)

Benefit Payable:
Maturity Benefit As per Clause 3.1 of Part C
Death Benefit As per Clause 3.1 of Part C

Nominee details (under section 39 of the Insurance Act 1938)

Name of the Nominee (s) Relationship with Life Assured Gender Age (years) Nomination %
ADVIKA SINGH Daughter Female 9 100.00

Appointee details (Applicable in case the Nominee is a minor)

Name of the Appointee (s) Relationship with Nominee Gender Age (years)
VIRENDRA SINGH PARENTS Male 42

Agent/Intermediary Name Agency/Intermediary Code Agent/Intermediary Contact details

POLICYBAZAAR INSURANCE BROKERS PRIVATE
004665695 18002585970 / care@policybazaar.com
LIMITED

CKYC

On examination of the Policy, if you notice any mistake, please return the Policy to the Company immediately for correction.

#HarWaqtKeLiyeTaiyaar Go to Table of Contents 5/46

 OTHER ENDORSEMENT

#HarWaqtKeLiyeTaiyaar Go to Table of Contents 6/46

 KEY FEATURE DOCUMENT
This is Non-Linked, Non-Participating, Pure Risk, Individual Life Insurance Product
that will help you secure the financial future of your loved ones.
You've selected the Life Promise Option under this product.
This is a Pure risk variant: Death benefit will be paid to the nominee.

Benefits you've opted for under the plan

Life Cover
Secures the financial future of your loved ones

Life Stage Option, if chosen

Option to increase life cover at important stages of life

50% of your base sum assured is paid out on diagnosis of a terminal illness and all future premiums are
waived off

FlexiPay Benefit1
Option to defer premium by up to 12 months with prior intimation. The defered premium will be recovered along
with the next premium.

Instant Payout on claim intimation2

Avail an accelerated instant death benefit of INR 3 Lacs from Sum Assured on claim intimation by providing basic
documents3

Wellness benefit with Tata AIA Vitality riders (if chosen):

A Wellness Program that offers you an upfront discount on rider premium.
You can also earn premium discount/cover booster (as applicable) for subsequent years on policy anniversary basis
Vitality Status tracked through the Tata AIA Vitality app.
Vitality Status: Stay active to avoid an increase in premium at Bronze or Silver status, and be rewarded for your fitness
with a discount at Gold and Platinum status. Check Vitality welcome letter for more information.

Maturity Benefit

Death Benefit

nominee is as outlined below:

(i) 1.25 x Single Premium (excluding discount) or DB multiple x Annualised Premium (excluding discount);
(ii) 105% of Total Premiums Paid (excluding loading for modal premiums and discount) up to date of death; or
(iii) An absolute amount assured to be paid on death

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 Grace Period Waiting Period
Monthly Mode: 15 days | Other Modes: 30 days This is applicable only if the product is bought
under POS. 90 days from the Date of commencement
of risk | Not applicable for death due to accident

Exclusion
In case of death due to suicide within 12 months:
- From the date of commencement of risk under the policy or from the date of revival of the policy, as applicable, the nominee
or beneficiary of the policyholder shall be entitled to at least 80% of the Total Premiums Paid till the date of death or the
surrender value available as on the date of death whichever is higher, provided the policy is in force; or
- From the date of exercising the Life Stage Option (if applicable), the nominee or beneficiary of the policyholder shall be
entitled to 80% of the premiums paid (excluding any extra premium, any rider premium and taxes) for the increased
tranche(s). The original death benefit (based on the sum assured chosen at the time of purchase) and any increased death
benefit purchased by exercising the Life Stage Option subsequently but prior to 12 months from the date of death (due to
suicide) will remain payable in full.
Terminal Illness:
- No claim will be payable if the condition arises directly or indirectly because of attempted suicide in the first year from
inception or revival of policy.
- In case a Terminal Illness claim is not payable due to the above exclusions, the policy will continue with the applicable death
cover.

Disclaimers:
1
With FlexiPay Benefit, policyholder is allowed to defer the due premium for a period of 12 months while maintaining the full risk
cover under the base plan and attached riders. At the end of Premium Deferment period, the policyholder is required to pay the
due premiums, including the premium applicable for the period of Premium Deferment, i.e. the base cover premium and
additional premium (if any). | This benefit shall be available for multiple times with a gap of 5 policy years from the expiry date
of previous Premium Deferment. The option can be exercised only after payment of 5 full years premium. | No interest shall be
levied on the premium due during the Premium Deferment period. If the premiums due are not paid within the grace period after
expiry of the Premium Deferment, the Policy (including Rider(s), if any) shall lapse and no benefits shall be payable in the Policy
or the Rider(s), if any) and company shall be entitled to recover the same from any amounts or benefits payable under the Policy
or Rider(s). | Please refer the sales brochure and policy document for more details.
2
With this feature, instant death benefit of INR 3 Lacs from the Sum Assured will be paid within 1 working day from the claim
registration date. This feature is applicable only after a waiting period of 3 policy years from the policy inception or revival of the
policy and provided the policy is in force. The remaining SA shall be payable post the completion of the claim investigation.
Further, in case of any discrepancy in the claim investigation resulting in the final decision of non-payment of the claim, the
company reserves the right to recover the already paid amount. The acceleration of instant claim should not be
construed/interpreted as acceptance of the claim.
3
On assessment of documents submitted during claim assessment, additional documents may be sought by the company. |
Please refer the sales brochure and policy document for more details.

To ensure that you get the maximum benefits from your policy features and to successfully achieve your financial goal,
it is recommended to stay invested and regularly pay premium through your policy term / premium payment term

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 SERVICE OPTIONS

Log in to one stop shop for your servicing needs

My
DigiAccount

How to login?
Visit https://myinsurance.tataaia.com

Authenticate your policy details and date of birth

Verify your registration via OTP

Your registration is now complete

Features

Simplifed OTP-based login Buy products online

single dashboard with

key policy information Easy servicing options

Pay premium, download Read interesting

receipts & statements blogs & articles

Set notification on
policy milestones

Where to pay premium

Pay on Website
Bank Website
https://apps.tataaia.com/PG/#!/policyPayment

Apps (PayZapp, Paytm, Google Pay,

My DigiAccount
Phone Pe, Jio Money, Airtel Money,
https://myinsurance.tataaia.com Itz Cash, MobiKwik, Amazon Pay)

Go to Table of Contents 9/46

How to pay premium?

Credit card/debit card

Netbanking

Mobile wallets

Bharat Bill Payment System (BBPS)

UPI

Watch our video on premium payment options

https://youtu.be/Dg1CYdlBa8w

Hassle-free Standing Instructions

Ensure Non-Stop Rakshakaran by registering for Standing Instructions where premium amount
will automatically get debited on due date.

Register on https://apps.tataaia.com/PG/#!/RegAutoDebt using Credit Card or Bank Account

Ways to access digital policy document

SMS Email WhatsApp My DigiAccount DigiLocker e-Insurance

Account

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Claims Process
Claim with ease

Step 1 Register claim with necessary documentation

Step 2 Documents are verified and claim is processed

Step 3 Claim amount is disbursed

Options to inform us

claims@tataaia.com

Type CLAIM & send to +91 7045669966

Visit our website

https://www.tataaia.com/customer-service/claim-registration.html

Locate your nearest branch from

https://www.tataaia.com/contact-us.html?contactUs-2

Write to us at Tata AIA Life Insurance Company Limited, Claims department, 9th Floor,
B wing, I-Think Techno Campus (Lodha), Behind TCS, Pokhran Road No.2, Thane
(West), Mumbai – 400607

Watch our claim settlement process on https://youtu.be/BaIjmQ5X6k0

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 Connect with us for any query/request

customercare@tataaia.com www.tataaia.com

Send Hi to +91 7045669966

1-860-266-9966 (Mon - Sat | 10 am - 7 pm IST),

022-6251 9966 (Outside India)

SMS PCT <space> Policy no.<space>

Registered Email ID to 5676799

Locate your nearest branch from

https://www.tataaia.com/contact-us.html?contactUs-2

Frequently Asked Questions

• Login to My DigiAccount from

https://myinsurance.tataaia.com
How to update personal details? • You can update name, email ID, mobile number,
NEFT details, PAN, address,
Standing Instructions details here.

• Digital document is equivalent to physical document. If

I need my physical policy document.
you still need it, you can send an email to
How can I get it?
customercare@tataaia.com requesting for a copy.
customercare@tataaia.com

• Login to My DigiAccount from

Need to update nominee/beneficiary? https://myinsurance.tataaia.com
• Visit any Tata AIA Life Insurance branch

• Send a request by logging to My DigiAccount from

Need to change your
payment frequency? https://myinsurance.tataaia.com
• Visit any Tata AIA Life Insurance branch

Need to know about Freelook Charges? Refer to Freelook Cancellation Clause of the T&C, in case you
exercise freelook option to cancel the policy, you shall
receive all premiums paid without interest after the
deduction of proportionate risk premium for the period of
cover, stamp duty as mentioned on the preamble page of the
policy document, medical examination costs and taxes as
applicable. Kindly note that if you have chosen monthly mode
of premium payment, the total deductible charges may be
higher than the amount of modal premium paid by you.

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 Customer Information Sheet/Know Your Policy
This document provides key information about your policy and will be included as part of your policy kit.
You are also advised to go through your policy document.

Sr Title Description in Simple Words Policy

No (Please refer to applicable Policy Clause Number in next column) Clause
number
01. Name of Tata AIA Sampoorna Raksha Promise (UIN: 110N176V02) Policy
Insurance Schedule
Product/Rider
and Unique
Identification
Number
02. Policy C237338956 Policy
Number Schedule
03. Type of Pure risk Policy
Insurance Schedule
Policy
04. Basic Policy Instalment Premium: 1,340 Policy
Details Mode of Premium Payment: Monthly Schedule
Sum Assured on Death: 99,00,000.00 / Benefit
Sum Assured on Maturity: As per Clause 3.1of Part C Illustration/
Premium Payment Term: 35 As per
Policy Term: 35 years Part C
05. Policy Benefits payable on maturity: Clause
Coverage/ Lump Sum Payout on survival of the life assured/s till the maturity 3(1)(IV)
Benefits date of the policy of part
Payable C

Benefits payable on death -

Life Promise / Life Promise Plus options:

In case of death of the Life Insured for an in-force policy (all due
premiums have been paid), the death benefit payable to the Claimant
is as outlined below:
Clause
Highest of: 3(1)(I) of
l 1.25 x Single Premium (excluding discount) or DB multiple(1) x part C
Annualised Premium(2) (excluding discount);
l 105% of Total Premiums Paid (excluding loading for modal
premiums and discount) up to date of death; or
l An absolute amount assured to be paid on death(3)
(1)
DB multiple is 7 in case of Life Promise Option and 10 in case of
Life Promise Plus option
(2)
in aggregate for Base SA and all tranches of Additional Sum
Assured
(3)
The absolute amount assured to be paid on death is the Effective
Sum Assured applicable as on the date of death.

Upon payment of entire sum of the death benefit, the policy

terminates and no further benefits are payable.

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
Terminal Illness
Terminal Illness payout is payable in lumpsum on the confirmed
diagnosis of the Terminal Illness as per the Option chosen by the you
and as detailed below:

Life Promise / Life Promise Plus Clause

In case of confirmed diagnosis of terminal illness of the life 3(1)(II) of
assured for an in-force policy (all due premiums have been paid): part C
The amount payable under the “Payor Accelerator Benefit” shall
be 50% of Base SA and all the future premiums (base benefit
option and cover enhancement options, if opted) shall be waived
off and the policy will continue to remain inforce for the remaining
applicable benefit(s).

Surrender Benefit:

The surrender benefit available under the product varies by the

Option chosen. The policy will terminate upon payment of this benefit. Clause
3(1)(III) of
Under Life Promise and Joint Life Promise option, we will pay part C
Unexpired Risk Premium Value on surrender which shall be as
mentioned in the Policy document.

The surrender value shall be equal to the higher of the Guaranteed

Surrender Value (GSV) and the Special Surrender Value (SSV).

Refer the policy document for more details

Options to policyholders for availing benefits, if any, covered

under the policy

Flexible Payout Option Clause 6.7

(II) of Part
You will have the option to opt for lump sum, staggered benefit or a F
combination of a lump sum amount and staggered benefit, as at the
time of purchase (referred as the “Payout Plan” henceforth).

If the payout plan chosen includes a staggered benefit, at the time of

purchase of the policy, the Policyholder would stipulate the benefit
amount stream payable to the nominee after death of the Life Insured.
The staggered benefit payment frequency can be Annual / Half Yearly
/ Quarterly / Monthly. Any accrued staggered benefit, due before
intimation of death, will be paid along with first payout under this
option. You can choose between:

a) Level income payout – fixed income payout throughout the

chosen benefit period
b) Increasing Income payout – income increases year-on-year
based on chosen simple interest rate (up to 15%) throughout
the chosen benefit period Clause 3

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
(II) (1) of
Cover Enhancement Options Part C

a) Life Stage:

Under Life Stage option, you can increase the coverage amount
on happening of any one of the following Life Stage events, and
the option to increase the Sum Assured is exercised within 180
days of the happening/incidence of the following event(s):

Additional Sum Assured

Event
as % of Base Sum Assured
Marriage (One Marriage
50%
Only)

Birth/Adoption of 1st Child 25%

Birth/Adoption of 2nd Child 25%

100%
Home Loan disbursal*
(subject to underwriting)
Clause 3
Once chosen, the option cannot be changed over the Policy Term, (II) (2) of
but you will always have a right to stop exercising the option in the Part C
future.

Refer the policy document for more details.

Top-Up SA

Under Top-Up SA option, you can opt to increase the life cover by a
fixed percentage at each Policy Anniversary by paying an additional
premium for every increase, subject to satisfactory underwriting as
per Underwriting Policy. You can opt to exercise the Top-SA option at
the time of purchase of the Policy, provided the premium payment
term is at least 5 years.

Refer the policy document for more details.

Other benefits/ options payable, specific to the policy, if any

Renewability option at Maturity:

At the Date of Maturity, You can choose to extend the Policy Term.
This option can be exercised a maximum of 5 (five) times subject to
Underwriting Policy. Additional premium shall be payable for the
extended term.

Cover Continuation Option:

In case of first death of either of the life assureds during the policy

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
term under Joint Life Promise and Joint Life Promise Plus, the
surviving life may choose to continue his / her life cover by taking a
Single Premium policy. The premium for the Single Premium policy
shall be determined based on attained age, chosen sum assured and
policy term. The Single Premium policy shall be chosen from Life
Promise, Life Promise Plus options. The Single Premium amount
shall be deducted from the death benefit payable with respect to first
death. This option has to be chosen at inception of the policy,
however the surviving life assured has a choice to not exercise this
option at later date.
Clause 3
Flexi Pay Benefit: (II) (3) of
You may opt to defer the due Premium for a period of up to 12 Part C
(twelve) months from the due date (“Premium Deferment Period”),
while maintaining the full risk cover under the Policy and the attached
riders, if any, at no additional cost/Premium. In case of occurrence of
any insured event during the said period of 12 (twelve) months, the Clause 3
Sum Assured shall be paid after deducting the unpaid Premiums, if (II) (4) of
any, as on date of the occurrence of the insured event covered under Part C
this Policy and the attached riders (if any).

At the end of Premium Deferment Period, You are required to pay the
due Premiums, including the Premium applicable for the Premium
Deferment Period, i.e. the base cover premium and additional
premium (if any). During the Premium Deferment Period, the Policy
shall remain in-force with the benefits applicable under Grace Period
of the Policy.

The Policy document lays down, in detail, the conditions specific to Clause 3
Flexi Pay Benefit (II) (5) of
Part C
Instant Payout on Claim Intimation:
In case of death of the Life Insured, post completion of waiting period
of 3 Policy Year, from the policy inception or Revival of the Policy and
provided the Policy is in force, an accelerated instant death benefit of
INR 3 Lacs from the Sum Assured will be paid within 1 working day
from the claim registration date. This feature could only be availed
with the minimum Sum Assured of INR 1 Cr.

The remaining SA shall be payable post the completion of the claim

investigation. Further, in case of any discrepancy in the claim
investigation resulting in the final decision of non-payment of the
claim, the company reserves the right to recover the already paid
amount.

Family Plan Option:

The Life insured at the inception (on payment of additional premium)
shall have an option to transfer Legacy Sum Assured to his/her child Clause 3
provided the policy is inforce and the primary Life insured survives till (II) (6) of
the end of their policy term. The optional benefit will work as follows: Part C

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number

Primary Life (Benefits defined for Life Promise /Life Promise Plus
option as mentioned above)
l The Primary Life Insured (i.e. Parent) coverage shall be
applicable during the Policy Term wherein the available
coverage terms for Primary Life are till Age 60 or 65 years as
per the base plan.
l Upon death or terminal illness of the Primary life during the
policy term, death or payor accelerated benefit, as applicable,
shall be payable and the policy will terminate thereafter.
l Upon survival of the primary life till the end of the Policy Term,
the primary life shall receive Return of Premiums in case of Life Clause 3
Promise Plus options and no benefit shall be applicable under (II) (7) of
Life Promise option. The Sum Assured (including any Top-up or Part C
Life stage option) of the primary life shall be transferred to the
secondary life thereafter.

Secondary Life
l Upon survival of the primary life till the end of the Policy Term;
provided the secondary life (i.e. one Child, as opted at the
inception) is alive, the coverage will commence for the
Secondary Life Insured and shall be covered till the Extended
Policy Term.
l The Extended Policy Term shall start post the coverage period
of primary life and will continue till the secondary life reaches
Age 60.
l Upon death of the Secondary Life Insured, the Sum Assured
shall be payable and the policy will terminate thereafter.
l Upon survival of the secondary life during the extended period,
no benefit shall be payable, and the policy will terminate
thereafter.

Addition clauses applicable

l This option is available only for Life Promise and Life Promise
Plus options.
l Minimum Age gap between primary and secondary life insured
should be 18 years.
l In case of death of secondary life insured before the policy term,
no further addition / change will be allowed.
l The life insured can opt for the benefit only at policy inception by
paying an incremental premium to avail the benefit.

Value-added Service Feature:

Health Management Services:
Life Insureds of TATA AIA Sampoorna Raksha Promise, who are
eligible for the Health Management Services, will be eligible to avail
second opinion/personal medical case management services/medical
consultation from the service provider/s affiliated to/registered with
Us. The services are expected to assist the Life Insured with an
independent diagnosis of the medical condition, thus helping the Life

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
Insured to take the required steps. These services are subject to a
number of conditions which have been detailed in the Policy
document.

LOYALTY PROGRAM REWARD Clause

If You are a member of the Loyalty Program administered by a 3(1)( V) of
service provider empaneled by the Company, You shall be entitled to part C
the Loyalty Program Reward upon the purchase of the Policy and
upon meeting the eligibility criteria. The loyalty programs offer
redemption benefits through the service provider’s eco-systems
based on applicable terms and conditions. Such reward shall accrue
as percentage of the Annualized Premium or Single Premium (as
applicable) and shall be made available by the service provider to
You in the form of benefits (points, coins, etc.) in the first policy year
by loyalty program service provider. The quantum of reward shall be Clause 3
determined by the Company’s extant Policy and shall be disclosed in (II) (8) of
the Company’s website from time to time. Part C

The loyalty program rewards benefit shall be subject to conditions

which have been detailed in the Policy document.

Lock-in period for Linked Insurance products: <<NA>>

06. Options NA
available (in
case of
Linked
Insurance
Products)
07. Option NA
available(in
case of
Annuity
product)
08. Riders opted, NA Rider CIS
if any
09. Exclusions SUICIDE EXCLUSION Clause
(events Suicide provisions will be applicable as per the Option selected by 4.3.1 of
where Policyholder and detailed as mentioned below: Part D
insurance
coverage is Life Promise, Life Promise Plus
not payable),
if any. In case of death due to suicide within 12 months:

From the date of commencement of risk under the policy or from the
date of revival of the policy, as applicable, the nominee or beneficiary
of the policyholder shall be entitled to at least 80% of the Total
Premiums Paid (including additional premium paid for Family Plan
Option benefit, if applicable) till the date of death or the surrender
value available as on the date of death whichever is higher, provided
the policy is in force; or Clause

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
4.3.2 of
From the date of exercising the Life Stage Option (if applicable), the Part D
nominee or beneficiary of the policyholder shall be entitled to 80% of
the premiums paid (excluding any extra premium, any rider premium
and taxes) for the increased tranche(s). The original death benefit
(based on the sum assured chosen at the time of purchase) and any
increased death benefit purchased by exercising the Life Stage
Option subsequently but prior to 12 months from the date of death
(due to suicide) will remain payable in full.

TERMINAL ILLNESS BENEFIT

No claim will be payable if the Terminal Illness arises directly or

indirectly as a result of attempt to suicide in the first year from
inception or Revival of policy.

In case a Terminal Illness claim is not payable due to the above

exclusion, the policy will continue with the applicable death cover.
10. Waiting/ lien NA Clause
period, if any 4.3.3 of
Part D
11. Grace Period A Grace Period of fifteen (15) days for monthly mode and thirty (30) Clause 6.3
days for all other modes, from the due date will be allowed for of Part F
payment of each subsequent premium. The Policy will remain in force
during this period. If any premium remains unpaid at the end of its
Grace Period, the Policy shall lapse and have no further value except
as may be provided under the Non-Forfeiture Provisions.

In case of death of the Life Insured during the Grace Period but
before the payment of the premium then due, the policy will still be
valid and the benefits shall be paid after deductions of the said unpaid
premium and also the balance premium(s), if any, falling due from the
date of death and before the next policy anniversary.
12. Freelook If you are not satisfied with the terms & conditions of the policy, you Clause
Period have the right to cancel the policy by providing a written notice to the 4.14 of
Company stating objections/reasons and receive the refund of all Part D
premiums paid without interest after deducting stamp duty and
medical examination cost along with applicable taxes, cesses and
levies which have been incurred for issuing the policy. Such notice
must be signed by you and received directly by the Company within
30 days from the date of receipt of the policy document whether the
Policy is sourced electronically or otherwise.
13. Lapse, Non-Forfeiture Benefit on Premium Discontinuance: Clause 6.
paid-up and 5 and 6.7
revival of the If any due premium for a non-single pay policy remains unpaid at the of Part F
Policy end of the grace period, the following is the treatment under various
scenarios:

Premium Paying Life Coverage Benefits Payable (if

options Before 2 After 2 applicable)

Go to Table of Contents 19/46

Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
years’ years’
premium premium
paid paid
Cover Cover
Regular
cease cease No amount is payable
Pay
to exist to exist
Unexpired Risk
Premium Value is paid
out on the earlier of the
following events after
Life which the policy
Promise terminates:
Cover Cover
Option Limited l Policyholder
cease cease
Pay surrenders
to exist to exist
voluntarily.
l Death of the Life
Insured
l Expiry of Revival
Period
l Maturity
Life Coverage
After one After one
Premium Paying Benefits Payable (if
full year’s full year’s
options applicable)
premium premium
paid paid
l Death Benefit as
defined in policy
document is
payable on death
of the Life Insured
l Payor Accelerator
Benefit is payable
Cover
on confirmed
continues
Regular diagnosis of
Cover with
or Terminal Illness
cease Reduced
Limited of the Life
to exist Paid-Up
Pay Insured.
Sum
l Surrender
Assured
Value/Unexpired
Risk Premium as
defined in policy
document is
payable.
l Maturity / Survival
Value as defined

REVIVAL

If a premium is in default beyond the Grace Period and subject to the

Policy not having been surrendered, it may be reinstated/revived,

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Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
within five years after the due date of first unpaid premium and before
the date of maturity, subject to: (i) Policyholder’s written application
for reinstatement/revival; (ii) production of Insured’s current health
certificate and other evidence of insurability, satisfactory to the
Company; and (iii) payment of all overdue premiums with interest.

Refer the policy document for more details.

14. Policy Loan, Not Available Clause 6.6

if applicable of Part F
15. Claims/Claims l Turn Around Time (TAT) for claims settlement and brief
Procedure procedure :
n 30 days from receiving all the documents,
n 90 days from the day of the claim intimation, if further
investigation required.
n Brief procedure :
i. Intimate claim to us via email/call/or at any one of the
branch offices.
ii. Submit all relevant documents along with claim. Please
refer to www.tataaia.com for more details.
iii. Documents shall be verified and processed.
iv. We shall contact you in case of any queries or further
information required.
v. Claim amount shall be disbursed if claim is acceptable.
vi. For the detailed procedure, please refer to our website
www.tataaia.com.
l Helpline/Call Centre number : 1-860-266-9966 (local charges
apply)
l Contact details of the insurer :
Email - Customercare@tataaia.com
Call our helpline number 1-860-266-9966 (local charges apply)
Write directly to us on following address:
Tata AIA Life Insurance Company Limited B - Wing, 9th Floor,
I-Think Techno Campus, Behind TCS, Pokhran Road No.2,
Close to Eastern Express Highway, Thane (West) – 400 607,
Maharashtra.
l Link for downloading claim form and list of documents required
including bank account details www.tataaia.com

16. Policy l Turn Around Time (TAT) : For Policy Servicing TATs, please Part G
Servicing visit www.tataaia.com
l Helpline/Call Centre number : 1-860-266-9966 (Call charges
apply)
l Contact details of the insurer : Email -
Customercare@tataaia.com Call our helpline number
1-860-266-9966 (local charges apply) Write directly to us on
following address: Tata AIA Life Insurance Company Limited B -
Wing, 9th Floor, I-Think Techno Campus, Behind TCS, Pokhran
Road No.2, Close to Eastern Express Highway, Thane (West) –
400 607, Maharashtra.

Go to Table of Contents 21/46

Sr Title Description in Simple Words Policy
No (Please refer to applicable Policy Clause Number in next column) Clause
number
l Link for downloading applicable forms and list of documents
required including bank account details www.tataaia.com

17. Grievances/ l Contact details of Grievance Redressal Officer of the Insurer Part G
Complaints Customers can email to GRO@tataaia.com or write to –
Grievance Redressal Officer (GRO) Tata AIA Life Insurance
Company Limited, 9th Floor, B - Wing, I-Think Techno Campus,
Behind TCS (Lodha), Thane (West), Mumbai – 400 607.
l Link for registering the grievance with the insurer’s portal The
Insurer’s portal may be accessed on www.tataaia.com.
l Contact details of Ombudsman
Where the redressal is not satisfactory despite the escalations, you
may represent to the Ombudsman. For further information or latest
updated list of Ombudsman Office addresses, kindly visit the IRDA of
India https://www.cioins.co.in/Ombudsman - Ombudsman / List of
Insurance Ombudsmen OR our website www.tataaia.com.

“We”, “Us”, “Our”, “Insurer” or “Company” refers to Tata AIA Life Insurance Company Limited.

Declaration by the Policy Holder:

I have read the above and confirm having noted the details. I further confirm the below that:

a) In case of any change to the Sum Insured/ Rider after submission of the proposal, the details in
the revised Benefit Illustration and Customer Information Sheet would be applicable.
b) I have received a copy of the CIS through the download utility/ through my Salesperson.
c) I am aware that on request I can avail of the CIS in local language.

Place:

Date: (Signature of the Policyholder)

This document has been authenticated with the OTP used to authenticate the proposal form

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 Tata AIA Life Insurance Company Limited.
COMMON PROPOSAL FORM
Kindly Fill the form in CAPITAL and only in blue or black
(For Official Use only)

Proposal Number: C237338956 Branch Code: MU01

Channel: Broking Campaign Code:
Sub Office Code: RM CAMS Code: 4967389
POS/Agent/Broker/Specified Person/Employee: Policy Bazaar
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 Please [ ] your answer
Is this policy self-proposed? Yes . If No, please answer the following details Type of Proposer: Individual
Relation with Life Assured: Self Type of Proposal:
II. ELECTRONIC INSURANCE ACCOUNT (eIA) DETAILS OF THE PROPOSER/POLICYOWNER
e-Insurance Account Number (eIA),if any
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 electronic
format electronic format
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 Limited
III. PRODUCT DETAILS
Premium ( )
Base Plan/ Rider Unit Premium Return of
Sum Policy (Inclusive of Premium
(Benefit Option) Linked Life Insured Name Paying Premium
Assured ( ) Term(Years) applicable taxes, Paying Mode
Name (Yes/No) Term(Years) option
cesses & levies )
Tata AIA
Sampoorna No Deepika Singh 9900000 35 35 1340 Monthly No
Raksha Promise

Base Plan/Rider Life Insured Details Benefit Payout Option Details

Benefit Payout
(Benefit Option) Income Income Income
Name Name DOB Gender Option Lumpsum ( )
p.a ( ) Duration(Years) Frequency

Tata AIA Vitality (Wellness Program Applicable only for specific product/riders): NA

Utilization of Rewards during the Premium Payment Term (if / is opted):

Kindly DATE BACK my Application to 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.

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

Funds for the chosen Portfolio Strategy (If Applicable )

OR
Debt oriented fund Equity oriented fund

Other Details(if applicable)

IV. PROPOSER / POLICYHOLDER DETAILS (Please fill in details of Life Assured if same as Proposer)
1. Title Mrs
2. Name Deepika Singh
3. Father's Name / Spouse Name Gyan prakash Singh
4. Mother's Name Suman Singh
5. Maiden Name(For female lives only) Deepika Singh
6. Gender/Date of Birth FEMALE/ 11-02-1989

Go to Table of Contents 23/46

7. Which is your Dominant Hand? (Question to be answered only if ADDL Rider is
selected )
8. Marital Status Married
9. Life Stage
Nationality: Resident Indian
Country of Residence : India
10. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
(If country of residence or nationality outside India then FATCA/ CRS-Self Certification Form
to be mandatorily completed)
11. Residence for Tax purposes in Jurisdiction(s) outside India No (If 'Yes' then FATCA/ CRS-Self Certification Form to be mandatorily completed)
12. Highest Educational Qualification Graduate
117/658k block Geeta nagar kanpur Geeta nagar
13. Correspondence Residence Address Landmark: Hari girls hostel City: KANPUR NAGAR
State: UTTAR PRADESH Country: India Pin code: 208025
117/658k block Geeta nagar kanpur Geeta nagar
14. Permanent/Updated Address/Registered office address Landmark: Hari girls hostel City: KANPUR NAGAR
State: UTTAR PRADESH Country: India Pin code: 208025
Residence No: +91 Mobile No: 6386990070
15. Telephone and Email Details
E-mail: singhdeepika13112010@gmail.com
16. Occupation Class Salaried
a. Name of Organisation /School / College Maduraj hospital pvt ltd
b. Organisation Type Private Limited
c. Industry Healthcare / Pharmaceutical
d. Nature of Work Administrative - Junior/Middle Management
e. Annual Income ( ) 400000
17. Income Proof
18. Identity Proof (In case of Passport & Driving License please mention expiry date) Aadhar Card, Uid
19. Address Proof for updated address Aadhar Card, Uid
20. Permanent Account Number ( PAN ) : DZSPS4955J (kindly attach copy of Pan card)
21. CKYC No. (If available)
22. Source of Funds

23. Are you a Politically Exposed Person? No ( Definition of PEP: "PEPs are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States
or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned corporations and 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")

IV. LIFE ASSURED DETAILS (Please fill in this section only if Life Assured is different from Proposer)
1. Title
2. Name
3. Maiden Name(For female lives only)
4. Gender/Date of Birth
5. Which is your Dominant Hand? (Question to be answered only if ADDL Rider is selected )
6. Marital Status

7. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
Country of Residence

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8. Life Stage
9. Highest Educational Qualification
10. Occupation Class
a) Name of Organisation/ School/College
b) Organisation Type
c) Industry
d) Nature of Work
e)Annual Income ( )
11. Income Proof
Expiry Date :
12. Identity Proof (In case of Passport & Driving License please mention expiry date)
Others :
13. Address Proof for updated address
14. Permanent Account Number (PAN): (kindly attach copy of Pan card)
15. Are you a Politically Exposed Person? (Definition of PEP: "PEPs are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States or
Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned corporations and 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

1. Nature of Age proof (Non-standard age proof submission will attract extra premium)
Aadhar Id Card - Standard
2. a) Height (cms or ft) 157.48cms b) Weight ( kg or lbs) 63Kg
PART A: LIFESTYLE DETAILS
1. Are you employed in the Armed Forces, Paramilitary, Police Forces, Fire Brigade or any other similar occupation? No
2. Is your occupation/your hobbies associated with any specific accident/health hazard or are dangerous in any way (e.g. working with dangerous or
corrosive chemicals, explosives, radiation, working underwater/underground or at height, working in mines, non-commercial flying activities, diving, No
mountaineering, any form of motorbike/car racing etc.)?
3. Have you ever been charge sheeted or convicted of any criminal proceedings or have any criminal case or charge pending against you in any
No
court of law in India or abroad? If Yes, please provide complete details.
4. Do you intend to live or travel outside India for more than 30 days for reason other than family vacation in next 6 months? No
5. Do you consume or have consumed any of the following? Please tick all relevant options and provide details
Substance Quantity/ Per Day for Tobacco & Per No. of If stopped consumption, mention month and year in
Yes/ No Consumed As
Consumed week for Alcohol and Narcotics Years which last consumed
Tobacco No
Alcohol No
Any Narcotics No

PART B: HEALTH & PERSONAL DETAILS

1. Has any of your insurance application or reinstatement application on life, accident, medical or health, critical illness, or disability ever been
No
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? No
3. Do you have any physical deformity / handicap or congenital defect / abnormality? No
4. Have you ever been advised to and / or have undergone any tests, investigations or surgery or had signs or symptoms of any condition, ailment
No
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:
a. Cardio: High or Low Blood Pressure / Raised Cholesterol / Chest Pain / Palpitation / Rheumatic Fever / Heart Murmur / Shortness of Breath /
No
Heart Attack / Stroke / Any other heart condition
b. Hormonal: High Blood Sugar/ Diabetes / Thyroid or endocrine disorder / Sugar in Urine / Any other hormonal disorder No
c. Respiratory: Asthma / Tuberculosis / chronic cough, chronic bronchitis, emphysema, pneumonia / Any other respiratory disorder No
d. Blood/Cellular: Cancer / Tumor or malignant growth / Leukemia / Anemia / Enlarged lymph nodes/ Any blood disorder No
e. Digestive/Regulatory: Recurrent indigestion / Gastritis / Stomach or Duodenal Ulcer / Hernia / Jaundice / Disorders of the liver / Cirrhosis and
No
Gastrointestinal System/ Any other disease

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 f. Mental/Psychiatric / Neurological ailment: Symptoms or ailment relating to Brain Depression / Anxiety / Brain Disorder or disease / Mental /
Psychiatric / Transient ischemic attack /Parkinson's disease / Multiple Sclerosis / Nervous disorder / Paralysis or Paraplegia / Epilepsy / Any other No
mental or psychiatric ailment
g. Neural/Skeletal/Muscular: Musculoskeletal disorders such as Arthritis / Recurrent Back Pain / muscular dystrophies/ musculoskeletal
deformities/ Slipped disc or any other disorder of Spine, Joints, Limbs or Leprosy; / Disorders of Eye, Ear, Nose,Throat including defective sight / No
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 Disease / Any
No
other disorder
i. Genitourinary: Hydrocele / fistula / piles / symptoms or ailment relating to Kidney / Kidney Stones/ Prostate, Urinary System or Reproductive
No
System / Any other disorder
6. Have you had/ are having any other illness or impairment not mentioned above? No
7. Are you presently in good health? Yes
8. Has any of your family member (Parents and Siblings) ever been diagnosed with diabetes, Hypertension, Kidney Failure, Cancer, Heart Attack or
No
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, angiography,
No
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? No
11. Female Life Questionnaire
a. Are you now Pregnant? If Yes, kindly state expected delivery date No
b. Have you undergone any gynecological investigations for illness, internal checkups, breast checks such as mammogram or biopsy? No
c. Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, fallopian tubes, menstruation, complications
No
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? 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)
Gender Date of
Family Details Name Occupation Annual Income ( ) Insurance Details (Existing /Applied for)
(Male/Female/Transgender) Birth
Father/Husband
First Child / Sibling
Second Child / Sibling
14. Family Details to be filled for Life Assured only Father Mother Brother Sister Spouse
a. If Alive, Health Status
b. If Deceased, Cause of Death
c. Age at Death/Current Age
VII. EXISTING INSURANCE DETAILS
Do you currently hold or have applied for Life Insurance/Pension/Health/Personal Accident Policies? Y / N If Yes, kindly provide details as below:
Life Assured Proposer (If Life Assured is Juvenile/Student/Housewife)
Type of Insurance (Life/ Health/ Unit Linked Company Basic Sum Type of Insurance (Life/ Health/ Unit Linked Company Basic Sum
/Pension/Personal Accident) Name Assured ( ) /Pension/Personal Accident) Name Assured ( )

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 Gender Percentage ( % ) (Do not enter % in decimals & total %
Name Date of Birth Relationship
(Benefit Option)Name (Male/Female/Transgender) should be equal to 100)
Tata AIA Sampoorna Advika
19-07-2015 Female Daughter 100
Raksha Promise Singh
IX. APPOINTEE DETAILS (Required only if Nominee is less than 18 years of age)
Name Date of Birth Gender (Male/Female/Transgender) Relationship
Virendra Singh 19-11-1982 Male Father

Go to Table of Contents 26/46

X. PAYMENT DETAILS
Premium Payment Method: Digital/Online Payment
Name of Credit Card/Debit Card Holder: Credit Card/Debit Card Number
Cheque/DD No. Issuing Bank Branch Amount Rs. 1340 Date: DD/MM/YYYY
Premium# 1136 + Taxes, cesses & levies 204 = Total Payment 1340 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:

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.
Name of Account Holder Bank Account No. Bank Name and Branch Account Type IFSC Code

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. 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 irrevocably 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 misrepresentation 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.
• I hereby consent that my KYC information (including FATCA/CRS) under this application form will be applicable to all my existing policies with the Company and supersede previous KYC
information. I understand that this KYC information will be used by the Company for determining my tax residential status for all statutory/regulatory reporting purposes
• Applicable for customer whose Date of Birth on the application form does not match with PAN card record: I hereby acknowledge that there is a difference in the date of birth provided in
my application form with my PAN card details. I hereby agree to submit alternate age proof document to be considered for my insurance application.
• Applicable for NRI/PIO/OCI customers in case of assisted sales: I am aware that Tata AIA Life is licensed to conduct life insurance business in India and understand that the premiums for the
insurance policy shall be received by Tata AIA Life in Indian Rupees from my declared source of income and will be paid from my own Indian current/ savings bank account, Non-Resident Ordinary
Account or Non-Resident External Account, Credit card or Debit Card. I confirm that this product has been solicited to me in person in India, or through email/ telephonic communication from India,
upon an enquiry initiated by me from my place of residence. I am aware of the laws and regulations as may be applicable to this proposal and undertake to comply the same from time to time. I
also undertake to inform the Company of any change in the above particulars, including residential status. In case of any failure to do so, I shall indemnify the Company for all losses and damages
incurred by the Company due to non-fulfillment of my aforesaid obligation to the Company.

Digitally signed through OTP on

22-12-2024 at 18:44:34 Date: 22-12-2024
Place: KANPUR NAGAR
Signature/Thumb Impression of Life Assured Signature/Thumb impression of Proposer
This OTP, received vide mobile no. 6386990070 , will be used to authenticate proposal form no. C237338956, Benefit Illustration no. C237338956, Customer
Information Sheet and suitability document on 22-12-2024 at 18:44:34

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 misrepresenting, 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 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

________________________________________________________________________________________________________________________________________

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 days from the date of submission of your proposal, please visit us at www.tataaia.com or call our helpline number 1860 266

Go to Table of Contents 27/46

9966 (local charges apply) or email us at customercare@tataaia.com.
This is only acknowledgement slip and not the premium receipt.

Agent code Agent name Signature of Agent Date of Acknowledgement

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 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) in ____________________ (language) and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer
responses to the information sought in the proposal form and I have read out the responses to the Proposer and he/she has confirmed that they are correct.

Date: 22-12-2024
Place: KANPUR NAGAR
(Signature of the person making the declaration)
Address of the person making the declaration:

Declaration by Proposer:
I have understood the contents of this proposal explained to me in language and confirm that the responses provided by me are correct.
Digitally signed through OTP on
Date: 22-12-2024 22-12-2024 at 18:44:34 Date:
Place: KANPUR NAGAR Place:
Signature/Thumb Impression of the Life Assured Signature/Thumb impression of Proposer

(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 IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public
AND FICTIOUS / FRAUDULENT OFFERS receiving such phone calls are requested to lodge a police complaint

Full Form for abbreviations used:

HUF – Hindu Undivided Family | MWPA – Married Women’s Property Act | OCI – Overseas Citizen of India | NRI – Non-Residential Indian
PIO – Person of Indian Origin | FATCA - Foreign Account Tax Compliance Act | CRS – Common Reporting Standard |CKYC – Central Know Your Customer

Area census code is an identifier of the location as rural / urban as per the latest census.

L&C/Advt/2022/Sep/2091/CAF/V1
________________________________________________________________________________________________________________________________________

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. Freelook 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 theperiod 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 customercare@tataaia.com. Visit us at: www.tataaia.com.

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BENEFIT ILLUSTRATION

Tata AIA Sampoorna Raksha Promise

Name of the Prospect/Policyholder Deepika Singh Proposal No: C237338956

:
Name of the Product: Tata AIA Sampoorna Raksha Promise
Age (years): 35
Tag Line: Non-linked, Non-Participating, Pure Risk, Individual Life
Gender: Female Insurance Product

Name of the Life Assured: Deepika Singh Unique Identification 110N176V02

Number:
Age (years) : 35
GST Rate : 18.00%
Gender: Female
GST Rate 2nd Year 18.00%
Smoker : No
onwards:
Policy Term (years): 35

Premium Payment Term (years): 35

Amount of Installment Premium 1,489

(Rs.):

Mode of Payment of Premium : Monthly

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details

Policy Option Life Promise Sum Assured Rs. 99,00,000

Sum Assured on Death (at inception of the policy) Rs. 99,00,000

Rider Details

Tata AIA
Vitality
Yes Utilisation of Rewards (if Wellness program opted) Premium Discount
(Wellness
Program):

Details of Life
Insured/Partner under Benefit Payout
Rider Name the Benefit Option
/
Return Premium
UIN^(Benefit Name Age Gender Lumpsum Income Increasing Income Income Last Income Benefit Premium Sum Year 1
of without
Option / (yrs) (Rs.) Payout Income frequency per Year's Duration Option Payment Assured Discount
premium GST
Benefit Type Rate* frequency Income (yrs) Term Term (Rs.) (Rs.)
chosen per option (Rs.)
Payout
Option) (Rs.) frequency
chosen
(Rs.)

Premium Summary

Base Plan Riders Total Instalment Premium

Instalment Premium without GST (Rs.) 1,262 0 1,262

Instalment Premium with First year GST (Rs.) 1,489 0 1,489

Instalment Premium post applicable discount with First year GST (Rs.) 1,340 0 1,340

Instalment Premium with GST 2nd year onwards (Rs.) 1,489 0 1,489

Discount applicable and Installment Premium payable 2nd year onwards will depend on the Wellness status of the Insured
Total Discount for first year premium Includes- Digital/Online Discount (10%)

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 (Amount in Rupees)

Guaranteed Non - Guaranteed

Policy Single/ Annualised Surrender
Year Premium Survival Benefit / Other Benefits, Maturity Death Min Guaranteed Special Surrender Value
Loyalty Additions if any Benefit Benefit Surrender Value Value

1 14,290 0 NA 0 99,00,000 0 0 0

2 14,290 0 NA 0 99,00,000 0 0 0

3 14,290 0 NA 0 99,00,000 0 0 0

4 14,290 0 NA 0 99,00,000 0 0 0

5 14,290 0 NA 0 99,00,000 0 0 0

6 14,290 0 NA 0 99,00,000 0 0 0

7 14,290 0 NA 0 99,00,000 0 0 0

8 14,290 0 NA 0 99,00,000 0 0 0

9 14,290 0 NA 0 99,00,000 0 0 0

10 14,290 0 NA 0 99,00,000 0 0 0

11 14,290 0 NA 0 99,00,000 0 0 0

12 14,290 0 NA 0 99,00,000 0 0 0

13 14,290 0 NA 0 99,00,000 0 0 0

14 14,290 0 NA 0 99,00,000 0 0 0

15 14,290 0 NA 0 99,00,000 0 0 0

16 14,290 0 NA 0 99,00,000 0 0 0

17 14,290 0 NA 0 99,00,000 0 0 0

18 14,290 0 NA 0 99,00,000 0 0 0

19 14,290 0 NA 0 99,00,000 0 0 0

20 14,290 0 NA 0 99,00,000 0 0 0

21 14,290 0 NA 0 99,00,000 0 0 0

22 14,290 0 NA 0 99,00,000 0 0 0

23 14,290 0 NA 0 99,00,000 0 0 0

24 14,290 0 NA 0 99,00,000 0 0 0

25 14,290 0 NA 0 99,00,000 0 0 0

26 14,290 0 NA 0 99,00,000 0 0 0

27 14,290 0 NA 0 99,00,000 0 0 0

28 14,290 0 NA 0 99,00,000 0 0 0

29 14,290 0 NA 0 99,00,000 0 0 0

30 14,290 0 NA 0 99,00,000 0 0 0

31 14,290 0 NA 0 99,00,000 0 0 0

32 14,290 0 NA 0 99,00,000 0 0 0

33 14,290 0 NA 0 99,00,000 0 0 0

34 14,290 0 NA 0 99,00,000 0 0 0

35 14,290 0 NA 0 99,00,000 0 0 0

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Note: "Annualized Premium” shall be the premium payable in a year under a non-single pay option chosen by the policyholder, excluding the taxes, rider premiums,
underwriting extra premiums, loading for modal premiums, if any.
"Single Premium” shall be the premium payable under a single pay option chosen by the policyholder, excluding the taxes, rider premiums, underwriting extra premiums,
if any.
#The benefits illustrated are as at the end of the policy year.
Policy sourced through Digital/Online mode.

I ______________ (name), have explained the premiums and benefits under the I ______________ (name), have received the information with respect to the
product fully to the prospect / policyholder. above, have understood the above statement before entering into the
contract.

Place:
Date: Signature of Agent / Intermediary / Official
Date: Signature of Prospect / Policyholder
Unique Reference Number - L&C/Advt/2024/Oct/3038 (Rider - L&C/Advt/2022/Sep/2271)

Tata AIA Life Insurance Company Ltd. (IRDA of India Regn No. 110) (CIN: U66010MH2000PLC128403)
Registered and 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 more information, Call the Tata AIA Life Insurance Company Ltd Helpline number 1860-266-9966 (local charges apply) or Visit us at: www.tataaia.com

Go to Table of Contents 32/46

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 FIRST PREMIUM RECEIPT
PERSONAL DETAILS
Tata AIA Sampoorna Raksha Promise
Policy Number: C237338956 Plan Name:
(110N176V02)
Policy Owner Name: Deepika Singh Life Assured Name: Deepika Singh
POLICYBAZAAR INSURANCE
Email ID: SINGHDEEPIKA13112010@GMAIL.COM Distributor/Agent Name:
BROKERS PRIVATE LIMITED
Contact No. : 6386990070 Distributor/Agent Contact Number:
PAN Details DZSPS4955J

PREMIUM DETAILS
Premium Amount Due (In Rs.) 1136.00 Payment Mode Monthly
Goods & Service Tax (GST) 204.00 Next Premium Due on 28/02/2025
Total Amount (In Rs.) 1340.00

TAX BENEFIT DETAILS

Life Insurance Premium (80C) Pension Plan (80CCC) Health Insurance Premium (80D)
1340.00 .00 .00

PAYMENT DETAILS
Receipt Number Receipt Date Amount (In Rs.) Payment Method
PP2227387 22/12/2024 1,340.00 Online Payment

*Life Insurance premiums are eligible for deduction under 80C, Pension plans under 80CCC and Health Insurance under 80D in accordance to specific
limits under prevailing Income Tax Act.

Please Note:
l This document can be used as a proof for claiming deduction while filling your tax returns and tax benefits would be applicable as per the prevailing
tax laws.
l Payments made through modes other than cash are subject to clearance including through electronic mode payments.
l Any excess premium will be adjusted towards premium due in the current financial year or due in the next three months, whichever is later. Else premium will be auto refunded post 15
days.
l Applicable govt taxes, surcharge, cess including GST would be charged in accordance with applicable Laws and Company will have the right to recover the same from the policyholder.
l Please refer to the policy document for detailed terms and conditions and our website for FAQ on applicable tax benefits.
l In case of Unit Linked Policy (ULIP), if premium is received by us after 3:00 pm on a business day, NAV of the next business day shall apply.

GST DETAILS
Base Premium Taxable Value CGST .00% SGST/UTGST .00% IGST 18.00% Reverse Charge
` 1136.00 ` 1136.00 ` .00 ` .00 ` 204.00
Tata AIA Life Insurance Tata AIA Life Insurance GST
HARYANA 06AABCT3784C1ZH SAC Description Life Insurance
State IN
UTTAR
Policy Owner's GST State Policy Owner's GSTIN SAC Code 997132
PRADESH

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