TataAIA/NB/DM/126.

Residence and Travel Questionnaire

Proposal No: ____________________ Full name: _________________________

1. Please provide details of your current residency and residential status including information of
duration of stay by visa etc, if appropriate.

______________________________________________________________________________
__________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Please provide details of your previous and future residence and travel (excluding holidays of
less than 4 weeks) :

Previous residence and travel (in the last 5 years)

Dates of Country and region Reason for Frequency (number of Duration of each
Stay of residence visiting trips per year) stay

Future residence and travel intentions (in the next 5 years)

Dates of Country and region Reason for Frequency (number of Duration of each
Stay of residence visiting trips per year) stay

3. Please provide a brief description of your occupational duties and/ or any other activities you
will participate while traveling or residing abroad.

______________________________________________________________________________
______________________________________________________________________________

Tata AIA Life Insurance Company Limited

.(IRDA Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/229
TataAIA/NB/DM/126.1

4. Do you expect to spend the majority of your time in major / large cities? Yes No
If NO, please provide the name of the town/ region and details of your likely accommodation,
availability of medical facilities and travel arrangements (e.g. light aircraft, boat etc.) :
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
________________________________________________________________________

5. Please give details of any medical treatment or surgery you have received while residing
overseas.
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
________________________________________________________________________

6. Please provide any additional information regarding your residence and travel which you feel
may be helpful in processing your application.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

I declare that the answers I have given are, to the best of my knowledge, true and I have not
withheld any material information that may influence the assessment of acceptance of this
proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to
disclose any material fact known to me may invalidate the contract.

Signature of Proposed insured:________________ Date:____________________

Signature of Applicant:____________________ Date:____________________

(If applicant is different from the proposed insured)

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

I__________________ holding ______________(ID card type) with number __________(ID card number)
hereby declare that I have explained the contents of this declaration to the Proposed Insured/Applicant in
________________ language and that the Proposed Insured/Applicant has affixed his/her signature/thumb
impression after fully understanding the contents thereof.

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

Tata AIA Life Insurance Company Limited

.(IRDA Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/229