Financial Questionnaire

Tata AIA/NB/DM/63
FINANCIAL QUESTIONNAIRE
Financial Questionnaire needs to be completed by the Proposed Insured / Applicant

Incomplete Financial Questionnaire would not be accepted and further pendings will be raised
PART I
Application Number.: __________________________
1. FULL NAME OF PROPOSED INSURED: ___________________________________________________

Full Name of Applicant: __________________________________________________________________
2. PURPOSE OF INSURANCE
Protection for Dependents Protection for Mortgage Loan
For Education Fund
Others (Please give details) _______________________________________________________________
3. Please give details of current life insurance in force (with Tata AIA or other companies) or solicited simultaneously on
proposed insured, applicant and family members.
Insurance Name of Insured Policy No. Coverage Premium (in Date of Issue
Company INR)
5. PAN / GIR No.: ___________________
6. INCOME DETAILS: Annual Income of the insured/applicant

Please provide accurate information of the annual income of insured for last 3 years. Please tick the relevant source of
information
ITR Computation of Income Audited individual accounts Self Assessment
Gross Income of last 03 years**: Rs______________ Rs____________ Rs______________

** (Including all commissions/ bonuses) Year _____________ Year ___________ Year _____________
Exempt/ Unearned income in the past 12 months:

Property Rental Income : Rs______________ Dividend from Shares : Rs_____________
Interest from Bank Deposit: : Rs______________ Other (please specify) : Rs_____________
Agricultural : Rs______________ Business (exempt) : Rs_____________
Tata AIA Life Insurance Company Limited

(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266-9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/245
Tata AIA/NB/DM/63
7a. ASSETS 7b. LIABILITIES
House/Other Property Rs. ___________________ Home Loan / Mortgage Rs. ____________

Motor Vehicles Rs. ___________________ Amount owing on vehicles, etc. Rs. ____________
Investments/ deposits Rs. ___________________ Personal Loans Rs. ____________
Shares, mutual funds Rs. ___________________ Overdraft Rs. ____________
Bonds/PPF/NSC Rs. ___________________
Other Assets (specify) Rs. ___________________ Other Liabilities (specify) Rs. ____________
_________________ Rs. ___________________ ____________________ Rs. ____________
_________________ Rs. ___________________ ____________________ Rs. ____________
Details of Fixed Assets (if owned)
Date of Purchase : __________________ Purchase Price : Rs_____________
Outstanding Mortgage : __________________ Current Value : Rs_____________
Other Properties Owned (If more than two properties, please use separate paper)
Property One Property Two
Address : ____________________________ ______________________________
____________________________ ______________________________
Date of Purchase : ____________________________ ______________________________
Purchase Price : ____________________________ ______________________________
Outstanding Mortgage : ____________________________ ______________________________
Car No. of car(s) owned ____________________________
Model of the car(s) : (1)____________________ (2)_________________ (3)__________________
8. FAMILY LIFE STYLE
No. of Dependents : ________________________________________________________________
Relationship : ________________________________________________________________
No. of Maid/Driver : ________________________________________________________________
Residential Property (if rented)

Monthly rental paid : Rs______________________ Paid by : ____________________________
9. JUVENILE INSURED
(To be filled only in case of Juvenile Insured)
a. How many brothers and sisters do they have age less than 18? ____________________________________________
b. If so, has (or is) insurance of a similar amount been effected on each child?
Yes No
c. If ‘Yes’, please provide Sum Assured on each ________________________________________________
d. If ‘No’, please give reason ________________________________________________________________

Tata AIA/NB/DM/63
10. BUSINESS DETAILS
Proposed Insured’s Percentage of Ownership in the Co. : _________________________________________

(Please also complete PART II if you own the company)
Commencement Date of the Business : _________________________________________
No. of Employees in the Co. : _________________________________________
Main Duties of the Proposed Insured in the Co. : _________________________________________
PART II
This part needs to be completed by all Self Employed / Individuals with Self Owned/Partnership Business
DETAILS OF BUSINESS INTEREST
- Name of Company: _________________________________________________________________________
- Name of Business: __________________________________________________________________________
- Nature of Business: _________________________________________________________________________
- Position held and for how long: _________________________________________________________________
Year ____________ Year ___________ Year ____________

CA Audited Accounts Yes No Yes No Yes No
Authorized Capital Rs______________ Rs_____________ Rs______________
Reserves & Surplus Rs______________ Rs_____________ Rs______________
Total Assets Rs______________ Rs_____________ Rs______________
Net Current Assets Rs______________ Rs_____________ Rs______________
Total Sales Rs______________ Rs_____________ Rs______________
Total Expenses Rs______________ Rs_______________ Rs______________
Gross Profit Rs______________ Rs_____________ Rs______________
Depreciation Claimed Rs______________ Rs_____________ Rs______________
Net Profit After Tax Rs______________ Rs_____________ Rs______________
*******************************************************************************************************
DECLARATION
I/We hereby declare that to the best of my/our knowledge, the foregoing statements are true and complete and that such
disclosures will form part of the basis of this Contract of life assurance.
Signature of Proposed Insured: _____________________________________ Date: _________________
Signature of Applicant: ____________________________________________ Date: _________________

Tata AIA/NB/DM/63
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


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Tata AIA/NB/DM/63

Financial Questionnaire needs to be completed by the Proposed Insured / Applicant

1. FULL NAME OF PROPOSED INSURED: ___________________________________________________

5. PAN / GIR No.: ___________________

6. INCOME DETAILS: Annual Income of the insured/applicant

ITR Computation of Income Audited individual accounts Self Assessment

Gross Income of last 03 years**: Rs______________ Rs____________ Rs______________

Exempt/ Unearned income in the past 12 months:

Tata AIA Life Insurance Company Limited

7a. ASSETS 7b. LIABILITIES

House/Other Property Rs. ___________________ Home Loan / Mortgage Rs. ____________

8. FAMILY LIFE STYLE

No. of Dependents : ________________________________________________________________

No. of Maid/Driver : ________________________________________________________________

Residential Property (if rented)

c. If ‘Yes’, please provide Sum Assured on each ________________________________________________

d. If ‘No’, please give reason ________________________________________________________________

Tata AIA Life Insurance Company Limited

10. BUSINESS DETAILS

Proposed Insured’s Percentage of Ownership in the Co. : _________________________________________

Commencement Date of the Business : _________________________________________

No. of Employees in the Co. : _________________________________________

Main Duties of the Proposed Insured in the Co. : _________________________________________

DETAILS OF BUSINESS INTEREST

- Name of Company: _________________________________________________________________________

- Name of Business: __________________________________________________________________________

- Nature of Business: _________________________________________________________________________

- Position held and for how long: _________________________________________________________________

Year ____________ Year ___________ Year ____________

Signature of Proposed Insured: _____________________________________ Date: _________________

Signature of Applicant: ____________________________________________ Date: _________________

Tata AIA Life Insurance Company Limited

Tata AIA Life Insurance Company Limited

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Gross Income of last 03 years**: Rs Rs Rs

House/Other Property Rs. _______ Home Loan / Mortgage Rs.

Year ______ Year _ Year ________

Signature of Proposed Insured: _____________________ Date: _

Signature of Applicant: ____________________________ Date: _