TATA AIA LIFE INSURANCE COMPANY LIMITED

Payor Annexure
PERSONAL DETAILS OF PAYOR
This Annexure is to be completely filled in when the Payor is different from the Proposer/ Life Assured. Kindly follow
the instruction mentioned in the proposal form.
Please affix
Proposal No:
recent
PERSONAL DETAILS
photograph of
the Payor
1. Title Mr. Ms. Mrs. Dr.
First
2. Name Middle
Last
3. Father`s Name
4. Mother`s Name
5. Spouse Name
6. Maiden Name
(female Lives only)
7. Gender and Date Male Female D D M M Y Y Y Y
of Birth
8. Nationality (#Other than Resident Indian NRI PIO Foreign National (Nationality) ______________________________________
resident Indian please #
mention current country Country of Residence ____________________________________
of residence)
9. Current
address(submit proof)
Landmark:
City: State: Pin Code:
10. Permanent Address
(submit proof)

Landmark:
City: State: Pin Code:
11. Telephone Residence No. S T D
and Email Official No. S T D
Details Mobile No.
E-mail Id
12. Relationship with
Life assured

13. Occupation Type Salaried Self Emp. Retired Others (Specify)______________________________

14. Organisation Type Public Ltd Pvt Ltd Professional Proprietary Others (Specify)______________________________
15. Annual Income
(including income from r______________________ per annum 16. Pan Card No:
all sources)
17. Identity Proof Passport Pan Card Aadhaar card Driving License Others Specify ID proof no__________
18. Income Proof ITR P& L account CA Certificate Others __________________________
19. Address Proof Voter's ID Telephone Bill Electricity Bill Others (Specify) _______________________________
20. (a) Are you a Politically exposed person? **(If yes, please provide details__________________________________________________________
(b) Are any of your family members or close relative a politically exposed person? Yes No
**Definition of PEP: Politically exposed persons are individuals who are or have been entrusted with prominent public functions in a foreign
country e.g. Heads of States or of Governments, senior politicians, senior government /judicial / military officers, senior executives of state-
owned corporations, important political party officials etc. It should also include persons who are affiliated to a Domestic political party / Central
or State Government or any government official not below the rank of an Under-secretary.
21. Have you ever been convicted of any criminal proceedings under any court of law in India or abroad?
If yes, please give details _____________________________________________________________________________________
22. PREVIOUS POLICY DETAILS (Details of Life Insurance/Health/Personal Accident Policies held/applied with Tata AIA Life or other companies in the capacity of Payor)
Company Name Basic Sum Assured Annual Premium Status
DECLARATIONS
Anti Money Laundering Declaration: I hereby Declare that: 1. The premium paid or would be paid has been derived from legally declared
and assessed sources of income.2. I understand that 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 hereby declare that the above statements, answers and/or particulars given by me / us are true and correct and complete in all
respect to the best of my knowledge. I / We understand that the information provided herein shall form the basis of Insurance policy and
that the policy is subject to Board approved underwriting policy of the Insurance Company and the policy will come into force only after the
receipt of the premium chargeable.

Signature/Thumb Impression Signature/Thumb Impression

of the Payor: of Life Assured:

Signature of the Agent

/ Specified Person/ Signature/Thumb Impression
Broker/ Employee of Proposer:

Date of signing:- D D M M Y Y Y Y Place :- ________________________

IN CASE THE PAYOR IS UNEDUCATED OR IS SIGNING IN VERNACULAR

The thumb impression or signature of the Payor/ Proposer/ Life Assured should be attested by a person of standing whose identity can easily be
established and this declaration should be made by him/her.
I _____________________________________ (name) holding ______________ (Identity Card type) ____________________ (Identity Card no.) hereby
declare that I have explained the contents of the enrollment form to the Payor/ Proposer/ Life Assured in ______________ language and that I have
read out to the Payor/ Proposer/ Life Assured the answers to the questions dictated by the Payor/ Proposer/ Life Assured. The information/answers
filled in the proposal form are exact replication of the information/answers provided to me by the Payor/ Proposer/ Life Assured and that the Payor/
Proposer/ Life Assured has affixed his/her signature/thumb impression on the enrollment form after fully understanding the contents thereof

Signature/Thumb Impression Signature/Thumb Impression

of Life Assured of Proposer

Signature of Witness Signature/Thumb Impression of Payor

INCOME TAX ACT, 1961

Income Tax benefits would be available as per the prevailing income tax laws, subject to fulfillment of conditions stipulated therein. Tata
AIA Life Insurance Company Ltd. does not assume responsibility on tax implication mentioned anywhere in this document. Please consult
your own tax consultant to know the tax benefits available to you.
Section 41, Insurance Act 1938 Prohibition of Rebates: 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 prospectus or tables of the
Insurer. 2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five
hundred rupees.
L&C/Advt/2013/Aug/204.

Tata AIA Life Insurance Company Limited (Regn. No. 110)

Registered & Corporate Office Address: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
Visit us at www.tataaia.com or call our toll free no 1800 267 9966 or helpline no. 1860 266 9966 (local charges apply) or email us at [email protected] or SMS “LIFE” to 58888