Tata AIA Life Insurance Company Limited

Customer Confidential Report

This document has to be completed and submitted along with all application forms.

To be filled by the Advisor / Specified Person / Broker / Employee after meeting the Life Assured / Proposer with respect to underwriting risk assessment of the Life
Assured / Proposer:

I hereby state that I have made reasonable enquiries about the Life Assured / Proposer and I confirm the following:

Policy number: U069656327

Name of the Life Assured: PRASHANT SAMANTA
Name of the Proposer: PRASHANT SAMANTA

Life Assured Proposer

Question
(Y/N) (Y/N)
Are you aware of / have observed any information that may adversely effect underwriting conditions, including,
habits/ heath conditions;
No
Income inconsistency;
Other material facts

If answer to any of the above questions is YES, please provide details here

Declaration:
I hereby declare that the forgoing statements are true to the best of my knowledge and detailed enquiries done by me. I further declare that
I have verified the identity and address of the Life Assured / Proposer and the proof submitted for the same in original.
I have verified and ensured that the details (PAN / phone / contact details / NACH details) of the Life Assured / Proposer mentioned in the policy application form are correct.
I have appropriately enquired about the Life Assured / Proposer medical condition / habits /existing Insurance and I have disclosed all material facts correctly in the policy
application form.
In my view the Life Assured / Proposer lifestyle matches with the income declared by him as well as his financial background as assessed by me.
The Life Assured / Proposer has signed / authenticated the application form.
I have not withheld any information, which could impact the underwriting decision of the Proposal.
I have correctly explained product features, benefits and policy terms & conditions to the Life Assured / Proposer.
I have not made any improper payments to Goverment Officials or their Close Relatives to secure the business.
I have not made any statement to the Life Assured / Proposer contrary to the Code of Conduct.
I recommend this proposal for insurance.

Date: 16-08-2023
Signature/Authentication:
Place:

Agent/Specified Person/Employee Name: ABHIMANYU SINGH Agents/Employee Mobile Number: 9811191185

Agent/Specified Person/Employee Code: 5771206 Agents/Employee Home Telephone Number: 18602669966

Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A,
Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is
used by Tata AIA Life Insurance Company Ltd under a license. For any information including cancellation, claims and complaints, please contact our Insurance
Advisor / Intermediary or visit Tata AIA Life¿s nearest branch office or call 1-860-266-9966 (local charges apply) or write to us at customercare@tataaia.com.
Visit us at: www.tataaia.com. ¿ L & C/Misc/2021/Jun/0321.

BEWARE OF SPURIOUS / IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public
FRAUD PHONE CALLS! receiving such phone calls are requested to lodge a police complaint.