MATURITY CLAIM DISCHARGE VOUCHER – Unit Linked

I/We ________________________________________the Policy Holder/ Assignee do hereby acknowledge receipt from Tata AIA Life
Insurance Company Limited (the “Company”), the sum of ` (In words) including the amount of Bonus if any, in discharge of all
my/our claims and demands under the Policy number U___________ which matures on DD-MM-YYYY. This Indicative Maturity Amount is
calculated based on NAV of <DD-MMM-YYYY>. The actual Maturity Amount will be based on NAV as on maturity date and the amount could
be higher or lower than the stated amount. Further all applicable charges shall be deducted till maturity date. All the benefits under the policy
will cease to exist on the maturity of the policy and the policy would be cancelled.
PAN - ______________________________ (Please attach self attested copy of PAN Card of Policy holder/Assignee)

EIA No - ____________________________ IPIN -______________________________________

Annualised Premium^ - Rs XXXXXXXX.XX Base Sum Assured - Rs XXXXXXXX.XX

Rider Premium – Rs XXXXXXX..xx Rider Sum Assured – Rs XXXXXX.XX
Plan Name – XXXXXXXX Top up Sum Assured – Rs XXXXX.XX

Residence for Tax Purposes in Jurisdiction(s) outside India: Yes
/No
(If ‘Yes’ then mandatorily fill the FATCA & CRS-Self Certification Form)

Statement:
PAYABLE BENEFITS Amount in Rs
*Regular Premium Fund Value
*Top up Fund Value ( if any)
Bonus
Maturity Amount
*Deduction (if any)
Net Amount Payable = Rs
* The actual NAV applied will be that on Maturity date. As per contract, applicable Monthly Charges till maturity would also be deducted.
TDS, if applicable, will be charged at the time of final payout.
^
Annualised Premium is the amount of Premiums payable for a complete 12-months period excluding Goods and service tax (GST).
I want full payout on maturity date

OR

I want to opt for Settlement option:

You may choose to receive the amount in periodical payments over a period of time as provided in your policy contract
For frequency other than Annual, NEFT form is mandatory. Please fill in the attached NEFT form with personalized cheque to receive
direct credits in your bank account.

In case you wish to avail the Settlement Option, please fill in below details
Period of Settlement (maximum upto 5 years)

One Year Two Years Three Years Four Years Five Years

Frequency of Settlement of Payout

Monthly Quarterly Semi Annual Annual

Note: Settlement Units will be distributed equally as per Period & Mode of settlement chosen after administration charges. Settlement amount will be
depended on NAV as on Settlement Date. For Payout modes other than Annual, NEFT form is mandatory. The first Settlement payout will be made
on the date of maturity.
All fields are Mandatory. Original Policy Document should be submitted with this form. (not applicable in case EIA number and IPIN is provided)

Affix
Revenue
Stamp
_________________________________
of Re. 1 __________________________________
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 Signature of Policy holder/Claimant Signature of Witness
(I understand and agree to the disclaimer mentioned below in the form)
(If at the time of policy inception insured was less than 18 years, insured signature should be verified by original Policy Holder)

___________________________ _____________________________
Name of Policy holder/Claimant Name of Witness
Address _____________________________ Address____________________________
_______________________________ __________________________________
Relationship
Signed on (date) _________ at City_______ Signed on (date) _________ at City_____
(In case of Juvenile turning major, signatures of both old policy holder & the new policy holder (juvenile who is now a major) will be required. Signature of
Juvenile who has turned major to be mentioned above in section ‘Signature of Policy holder’ & the old policyholder’s signatures to be provided below.

___________________________________
Signature of old Policy holder/Claimant (in case policyholder is juvenile turned major)

Declaration in case the Policyholder is illiterate or signing in vernacular:

I ____________________________(name) with ________________(identify type) ________________ (identity number) hereby declare that I have
explained the contents of the Maturity Claim Voucher to the Policyholder in ___________________ language and that the policyholder has signed/
affixed his/ her thumb impression on the Maturity Claim Voucher after fully understanding the content thereof.

Signature of the witness ________________ Please affix Policyholder signature/thumb impression _________________.
Note:
1. All signatures must be in ink. Names should be written as they are in our record.
2. For each signatory, there should be a witness with the signature. The witness has to be 21years old or above, who is not the beneficiary of this
policy.
NOTES:
1. This discharge form must be signed by the Policy Holder and Witnessed by a person who is conversant with the language of this form and
knows the Policy Holder and whose identity can easily be established.
2. In case the claimant affixes thumb impression, the thumb impression must be attested by a Notary / Gazetted officer / Gram Panchayat Pradhan / Gram
Panchayat member / School headmaster / Ward councilor / Block Development Officer / Bank Manager/ SEM or a person of local standing provided
attestation is done after affixing a rubber stamp /giving his name & designation.
Where thumb marks are affixed attesting official must make the following declaration under the signature.

Shri/Smt ___________________________________________ son/daughter/spouse of Shri________________ __________________ has affixed

his/her thumb marks in my presence after understanding the contents there of.
______________________________
Signature of the official with seal of his office
Name : Designation : Date :

*Disclaimers:-
Indicative Maturity Amount is arrived at basis assumption that policy is in force on Maturity Date & all due premiums have been paid. The value is arrived at
basis current day NAV. The Value may change basis NAV applicable on Maturity Date, provided there is no settlement option chosen.
1. At the time of making the Maturity claim payment, if there is any premium outstanding, then we will deduct the outstanding premiums from Maturity
Amount. If the policy is already on Premium Holiday, Premium Holiday charges if applicable will be deducted.
2. The Net Amount Payable mentioned above does not include any excess amount received by the Company and which will be refunded to the
Policyholder along with the Maturity claim amount.
3. If there are any transactions such as Premium Payment, Partial Withdrawal, Fund Switch etc. which are carried out in the policy after the dispatch of
this Discharge Voucher, the same will be accordingly accounted in the Maturity Value.
4. During Settlement Period no life cover is provided. The maturity amount remains invested in chosen funds. No transactions such as Partial
Withdrawal, Fund Switch etc. will be allowed during the settlement period. In case of unfortunate death Total Fund Value will be paid to the nominee.
5. In case policy maturity date falls on non working day or Holiday, NEFT payout will be credited on the next working day.
6. In case of address change please provide the Request For Change Form along with the address proof
7. All applicable taxes, duties, surcharge, cesses or levies, as may be imposed by Government, any statutory or administrative authority from time to
time, on the premiums payable and benefits secured under Policy, shall be borne and paid by the Policyholder.
8. Income Tax benefits u/s 80C and 10(10D) 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.
PAN: AABCT3784C
Category of Service: Life Insurance Service and / or Management of investment under ULIP Services
Tata AIA Life Insurance Company Limited (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
For more Information, contact your advisor or call on our Helpline No 1-860-266-9966 (local charges apply) or
SMS “Service” to 58888 or e-mail us at customercare@tataaia.com or visit our website www.tataaia.com L&C/Misc/2017/Jun/232 Page 2 of 2, Version-6.5
BEWARE OF SPURIOUS PHONE CALLS AND FICITIOUS/FRADULENT OFFERS
IRDA of India clarifies to public that IRDA of India or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest
premiums.
IRDA of India does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call,
number.

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