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CDF - CCD For Hsec

This document is a customer declaration form for Tata AIA Life Insurance Company. It requests that the customer confirm details provided in an online application for life insurance. The customer confirms they understand the product features and that an advisor assisted in filling out the application accurately. The customer agrees to be bound by the statements made in the online application and understands the company may accept, decline, or modify the application terms. The customer also declares they are paying the premium from their own account. Signatures are required from the insured, proposer if different, and advisor to finalize the application.

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Nishanth Varma
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521 views1 page

CDF - CCD For Hsec

This document is a customer declaration form for Tata AIA Life Insurance Company. It requests that the customer confirm details provided in an online application for life insurance. The customer confirms they understand the product features and that an advisor assisted in filling out the application accurately. The customer agrees to be bound by the statements made in the online application and understands the company may accept, decline, or modify the application terms. The customer also declares they are paying the premium from their own account. Signatures are required from the insured, proposer if different, and advisor to finalize the application.

Uploaded by

Nishanth Varma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CUSTOMER DECLARATION FORM

Application No. Application No.

Application No. Application No.

PLEASE DO NOT FILL THIS DECLARATION IF THE ABOVE FIELD IS BLANK/EDITED

To ,

Tata AIA Life Insurance Company Ltd.

Subject: Submission of Online Application

I/We________________________________________________________________________________________ request you to process the above mentioned


Application/s Number for life insurance ___________________________________________________________, on the website www.tataaia.com / online sales
application of Tata AIA Life Insurance Company Ltd. ("the Company").

I/We confirm that I/ we have read relevant documentation/ information and have understood the product features and benefits. I/ We agree that post my/our
meeting with ________________________________________ bearing license/certificate number ______________________________. I/We hereby confirm that
Mr./Ms._______________________________________, has duly filled the details in the application form online in my/our presence and in accordance with the
information provided by me/us. I/We acknowledge that the information stated in the above application form is true and correct and I/we have duly checked
and verified the same. Further, I/we am/are submitting the requisite documents (Age/Address/Identity/Income Proof and photograph) as applicable for further
processing of this application.

I/ We understand and agree that by submitting this application through the Company's website / online sales application, I/ We will be bound by such
statements / disclosure of material facts in the same manner and to the same extent, as if I/ We have signed and submitted a written proposal for insurance
to the Company.

The Company reserves the right to accept, decline or offer alternate terms on this application for life insurance. I hereby declare and confirm that I am making
the premium payment towards this application through my own bank account/credit card.

Signature/Thumb impression of the Signature/Thumb impression of the Signature of Advisor/Specified Person


Person to be Insured Proposer (If different from the Person from Corporate
to be Insured) Agent/Broker/Distributor

Place: Date: Place: Date: Place: Date:

Applicants affixing thumb impression or signing in vernacular language, please ensure relevant confirmation from the witness as per below metioned
‘vernacular declaration’. In such cases it would be presumed that the witness would have explained contents of the form and this declaration to the applicant
before submission.

IN CASE ANSWERS TO THE QUESTIONS ARE FILLED IN BY A PERSON OTHER THAN THE PROPOSER OR WHERE THE ANSWERS / SIGNATURE OF THE
PROPOSER /LIFE ASSURED ARE IN VERNACULAR.
I,_______________________________________ (name) have explained the contents of this proposal to the _________________________________________
(Proposer/Life Assured) in _______________________________ (language) and ensured that the contents have been fully understood by him/ her. I have
accurately recorded the Proposer/Life Assured’s responses to the information sought in the proposal form and I have read out the responses to the Proposer/Life
Assured and he/ she has confirmed that they are correct.
Signature of the person making the declaration Place: _________________ Address of the person making the declaration: _______________________
Date: _________________ ________________________________________________________________

I have understood the contents of this proposal explained to me in __________________________________ language and confirm that the responses provided
by me are correct.
Signature / Thumb Impression of the Life Assured Place: _________________ Signature / Thumb Impression of the proposer Place: _________________
Date: _________________ Date: _________________

Website: www.tataaia.com • Helpline Nos.: 1800 267 9966 (toll free) 1860 266 9966 (local charges apply)
• email: [email protected] • SMS "SERVICE" to 58888.
Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No. 110 • CIN: U66010MH2000PLC128403).
Registered & Corporate Office Address: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
L&C/Advt/2015/Nov/598

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