KEY FEATURE DOCUMENT

Proposal Number C195711521

This document highlights the salient feature of the product and helps you to understand the “Key Features” available under the plan opted by you. For details on the terms, conditions,
features and charges please refer to the policy contract.

Plan Type This is a Non-Linked Non-Participating Individual Micro Insurance Pure Risk Premium Life Insurance Plan

Entry Age* Minimum: 18 years Maximum: 50 years

Maturity Age* Minimum: 23 years Maximum: 60 years

Minimum: Maximum:
Single Pay – 5 years 10 years, subject to maximum maturity age
Policy Term (PT)
Limited Pay – 6 years
Regular Pay – 5 years

Minimum: Maximum:
Premium Payment Term Single Pay – Lumpsum at policy inception Single Pay – Lumpsum at policy inception
(PPT) Limited Pay – 5 years Limited Pay – 9 years
Regular Pay – Equal to policy term Regular Pay – Equal to policy term

Premium Payment Mode Single/Annual/Semi-annual / Quarterly/Monthly

Minimum: 50,000 Maximum: 2,00,000

Basic Sum Assured
The Basic Sum Assured shall be in multiples of 50,000 only

Survival Benefit No survival benefit is payable

Maturity Benefit No maturity benefit is payable

In case of death of the life assured for an in-force policy (all due premiums have been paid), the death benefit payable to the nominee is as outlined
below:
Regular Pay / Limited Pay --
Highest of:
10 x Annualised Premium;
105% of Total Premiums Paid (excluding loading for modal premiums) up to date of death; or
An absolute amount assured to be paid on death1
Single Pay --
Death Benefit
Highest of:
125% x Single Premium; or
An absolute amount assured to be paid on death1
1The absolute amount assured to be paid on death is the Basic Sum Assured of the policy.
Upon payment of death benefit, the policy terminates, and no further benefits are payable.
In case of death of the life assured during the Grace Period but before the payment of the premium then due, the policy will still be valid and the
benefits shall be paid after deductions of the said unpaid premium and also the balance premium(s), if any, falling due from the date of death and
before the next policy anniversary.

If the policyholder is not satisfied with the terms & conditions of the policy, the policyholder has the right to cancel the Policy by providing written
notice to the Company and receive a refund of all premiums paid without interest after deducting a) Proportionate risk premium for the period on
Free Look Period cover, b) Stamp duty and medical examination costs, if any (including goods and services tax) which have been incurred for issuing the Policy.
Such notice must be signed by the policyholder and received directly by the Company within 15 days after the policyholder receives the Policy
Document. The said period of 15 days shall stand extended to 30 days, if the policy is sourced through electronic or distance marketing mode.

Grace Period If you are unable to pay your Premium on time, starting from the premium pay-to-date, a Grace Period of 15 days for monthly mode and 30 days for
all other modes will be offered. During this period your Policy is considered to be in-force with the risk cover as per the terms & conditions of the
Policy. If any claim occurs during the Grace Period, any due premiums (without interest) of the Policy, which are not paid as on date of death, will
be deducted from the death claim payout.

Lapse On discontinuance of payment of premium during the first 2 policy years, the policy will lapse and no further benefits shall be paid.

Policy Reviva If a premium is in default beyond the Grace Period and subject to the Policy not having been surrendered, it may be reinstated/revived, within five
years after the due date of first unpaid premium and before the date of maturity, subject to: (i) Policyholder’s written application for
reinstatement/revival; (ii) production of Insured’s current health certificate and other evidence of insurability, satisfactory to the Company; and (iii)
payment of all overdue premiums with interest.

Policy Loan Loan facility is not available in this Policy.

In case of death due to suicide within 12 months, from the date of commencement of risk under the policy or from the date of revival of the policy,
as applicable, the nominee or beneficiary of the policyholder shall be entitled to at least 80% of the Total Premiums Paid till the date of death or the
Exclusion
surrender value available as on the date of death whichever is higher, provided the policy is in force. The policy shall terminate, and no further
benefits shall be payable.

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 An Unexpired Risk Value (as stipulated below) is payable and after which the policy shall terminate.
Regular Pay:The Unexpired Risk Value will be zero.
Limited Pay:The Unexpired Risk Value is payable on the earlier of the following events, provided at least 2 consecutive full years of premiums
have been paid:
- Upon the Policyholder applying for the same before the stipulated date of maturity;
- At the end of revival period if the policy is not revived; or
- At the stipulated date of maturity.
The value payable is given as below:

(Unexpired Policy Term)

Unexpired Risk Value 70% X (Total Premiums Paid)# X
(Original Policy Term)
#Total Premiums Paid shall be inclusive of any extra premium, if any.
The Unexpired Risk Value payable will be zero in case at least 2 consecutive full years of premiums have not been paid.
Single Pay:The Unexpired Risk Value is payable upon the Policyholder applying for the same at any time after the policy is issued and before
the stipulated date of maturity. The value payable is given as below:

(Unexpired Policy Term)

70% X (Single Premium Paid)# X
(Original Policy Term)
#Single Premium shall be inclusive of any extra premium, if any.

*All reference to age is as on last birthday.

Kindly note that this document does not substitute the policy contract.

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. UIN: 110N169V01
• Unique Reference Number: L&C/Advt/2023/Sep/3046

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

2
Tata AIA Life Insurance Company Limited.
PROPOSAL FORM - MICRO INSURANCE
Kindly Fill the form in CAPITAL and only in blue or black
(For Official Use only)

Proposal Number: C195711521 Branch Code:

Campaign Code: Sub Office Code:

RM CAMS Code: 5441907 POS/Agent/Broker/Specified Person/Employee: NUR ALAM

Channel: RURAL

5343027

Customer Relationship No. (For Bancassurance Channel) PAN No.

IMPORTANT GUIDELINES: 1) Insurance is a contract of utmost good faith between the Insurer and the Insured. The Proposer and the Life to be Assured are required to disclose all
facts in response to the questions in this application form. 2) Any cancellation/alteration is to be signed by Proposer/Life to be assured as applicable. 3) KYC documents will be
required for all the parties to the contract.

I. GENERIC DETAILS

Is this policy self-proposed? Yes If No, please answer the following details Type of Proposer Individual Life

Relation with Life Assured Self Type of Proposal

II. ELECTRONIC INSURANCE ACCOUNT (eIA) DETAILS OF THE PROPOSER/POLICYOWNER

e-Insurance Account Number (eIA),if any,:

I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Tata AIA Life Insurance Company Ltd. in Electronic Format
(Physical copy would be sent even if proposer opts for electronic format; however, in case proposer has e-Insurance Account, only electronic copy of the Insurance Policy will be
provided)
I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Insurance Repository in the Electronic Format as and when
applicable. Please select the name of the Insurance Repository.
CAMS

III. PRODUCT DETAILS

Sum Policy Term(Years & Premium Paying Term(Years Premium ( ) (Inclusive of applicable taxes, Premium Paying
Base Plan / Rider (Benefit Option) Name
Assured ( ) Months) & Months) cesses & levies) Mode

Tata AIA Bharat Suraksha Cover Micro

50000 5 5 110 Quarterly
Insurance Plan - POS

Kindly DATE BACK my Application to DD/MM/YYYY 1. Allowed only as per product specifications 2. Allowed within the same financial year 3. In case of juvenile (less than 1 year)
back date is not allowed. 4. Date Back of policy is allowed only up to the official launch date of the product.

IV. PROPOSER / POLICYHOLDER DETAILS (Please fill in details of Life Assured if same as Proposer)

1. Title Mr.

2. Name Mosaraf Hossain

3. Father's Name / Spouse Name md mainuddin

4. Mother's Name moriom bibi

5. Maiden Name(For female lives only)

6. Gender/Date of Birth Male 12-06-1980

7. Marital Status Married

Resident Indian INDIA

Country of Residence : INDIA
8. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
(If country of residence or nationality outside India then FATCA/ CRS-Self Certification Form to be
mandatorily completed)

9. Residence for Tax purposes in Jurisdiction(s) outside India No (If Yes then FATCA/ CRS-Self Certification Form to be mandatorily completed)

- - NOMUNIA Kapasia North Dinajpur Itahar

10. Correspondence Address Landmark: NAMUNIA City: Kapasia

State: WEST BENGAL Country: INDIA Pin code: 733128

- - NOMUNIA Kapasia North Dinajpur Itahar

11. Permanent/Updated Address/ Registered office address Landmark: NAMUNIA City: Kapasia

State: WEST BENGAL Country: INDIA Pin code: 733128

12. Life Stage

Residence No. Mobile No. +91 8927432935

13. Telephone and Email Details
E-mail mosarraf629570@gmail.com

14. Occupation Class Self Employed

15. Name of Organisation /School / College mosaraf hossain

16. Annual Income ( ) 36000

17. Identity Proof (In case of Passport & Driving License please mention expiry Expiry Date :
date) xxxxxxxx0927

18. Address Proof for updated address

(kindly attach copy of Pan card)

19. Permanent Account Number ( PAN ) :
No I Do not have PAN (kindly attach copy of Form 60 duly signed)

20. CKYC No. (If available)

21. Are you a Politically Exposed Person? No. (Definition of PEP: "PEPs are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States or
Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned corporations and important political party officials;¿. ¿Close relations of PEP: Family members are
individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of partnership. Close associates are individuals closely connected to a PEP, either socially or professionally")

22. Area Census Code

23. Below Poverty Line Card Holder (BPL)

V. HEALTH & LIFESTYLE DETAILS OF THE LIFE ASSURED

1. Nature of Age proof (Non-standard age proof submission will attract extra premium)
Aadhar ID Card - Standard

2. a) Height (cms or ft) 152 cms b) Weight ( kg or lbs). 65 kgs

HEALTH DECLARATION OF LIFE ASSURED

Do you have any disorder of the heart or circulatory system, high blood pressure, stroke, asthma or other lung condition, cancer or tumor of any kind, diabetes, hepatitis or liver
condition, urinary or kidney disorder, depression, mental or psychiatric condition, epilepsy, HIV infection or a positive test to HIV, any disease of the brain or the nervous system, blood
disorder? Do you currently have, or received treatment for any medical conditions, disabilities? Do you suffer from any symptoms that have persisted for more than seven days? Do
you currently have, or have been admitted to a Hospital/Nursing Home for treatment or any symptoms, medical condition or disabilities? Have you ever been absent from work due to
illness or injury for a continuous period of more than 10 days during the last 03 years? No

VI. EXISTING INSURANCE DETAILS

Do you currently hold or have applied for Life Insurance/Pension/Health (Cancer/Cardiac/Critical Illness)/Personal Accident Policies? Y / N If Yes, kindly provide details as
below:

Life Assured

Type of Insurance (Life/ Health (Cancer/Cardiac/Critical Illness)/ Unit Linked /Pension/Personal Accident) Company Name Basic Sum Assured ( )

VII. NOMINEE DETAILS (Required only if Proposer & Life Assured are the same)

Name Date of Birth Gender (Male/Female/Transgender) Relationship Percentage ( % ) (Do not enter % in decimals & total % should be equal to 100)

jarina khatun 06-03-1988 Female Spouse 100

VIII. APPOINTEE DETAILS (Required only if Nominee is less than 18 years of age)

Name Date of Birth Gender (Male/Female/Transgender) Relationship

IX. PAYMENT DETAILS

Premium Payment Method: Digital/Online Payment

Name of Credit Card/Debit Card Holder: Credit Card/Debit Card Number
Cheque/DD No. Issuing Bank Branch Amount Date: DD/MM/YYYY
Premium# 110 + Taxes, cesses & levies 0 = Total Payment 110 for months initial deposit (To be filled for monthly mode only)

On the first policy/modal anniversary I would like to change the premium payment mode to , subject to policy contract provisions. For Annual/Monthly mode issued policies mode
change shall be accepted only on completion of first policy anniversary. #Premium is exclusive of applicable taxes, cesses & levies. All Premiums are subject to applicable taxes,
cesses & levies which will entirely be borne by the Policyholder and will always be paid by the Policyholder along with the payment of Premium. If any imposition (tax or otherwise) is
levied by any statutory or administrative body under the Policy, Tata AIA Life Insurance Company Limited reserves the right to claim the same from the Policyholder. Alternatively, Tata
AIA Life Insurance Company Limited has the right to deduct the amount from the benefits payable by Us under the Policy. Cheque/DD should be drawn in favor of ¿Tata AIA Life
Insurance Company Ltd. C195711521 (Proposal No)¿. Do not issue blank cheque.
Renewal Payment Mode: NACH (National Automated Clearing House)

X. Mandatory Bank Account Details:

Please provide below bank details. Bank details provided should be in the name of Proposer. All policy payouts will be made to the below mentioned bank account through electronic
transfer (NEFT). Payout would be in accordance and subject to terms and conditions of the policy.

Name of Account Holder Bank Account No. Bank Name and Branch Account Type IFSC Code

Mosaraf Hossain 34548038371 STATE BANK OF INDIA ITAHAR Saving SBIN0014077

Note: 1. Please provide a cancelled copy of your personalized cheque. If personalized cancelled cheque is not available, attach bank statement showing account holder name, address
and account number. 2. In case of Non-Credit to the given bank account with/without assigning any reason thereof or if the transaction is delayed or not effected at all for any reason of
incomplete information, Tata AIA Life Insurance Co Ltd will not be responsible. 3. Further, the Company reserves the right to use any alternative payout option inspite of opting for
Direct Credit option.

XI. Waiting Period (applicable only for POS products except Immediate Annuity Products):

In case of death of the life insured during the first 90 days from the date of commencement of risk, the claimant shall be entitled to the total premiums paid. Waiting period shall not be
applicable in case of death due to accident.

XII. DECLARATION & CONSENT

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all
respects to the best of my knowledge and that I am authorised to propose on behalf of these other persons (applicable where the proposer and life insured are different).
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy
will come into force only after full payment of the premium chargeable.
I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but
before communication of the risk acceptance by the company.
I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/ proposer or from
any past or present employer concerning anything which affects the physical or mental health of the person to be insured/ proposer and seeking information from any insurer to
whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer (if any) for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
I confirm that I have understood the contents of this Proposal Form and I am submitting this Proposal Form with all the details which are true and correct. I have not withheld any
material information or suppressed any fact which are essential for issuance of the policy. I also hereby irrevocably authorize the Company ascertain all the details from any third
parties, as may be required for assessing the risk.
I agree to undergo all medical tests as determined by the Company for obtaining the policy and I further understand that the Company reserves the right to issue the policy if all the
required criteria are met and in case of any fraud or misrepresentation being established, the insurer shall take action in accordance with Section 45 of the Insurance Act, 1938 as
amended time to time. I understand that the contract will be governed by the provisions of the Insurance Act, 1938 as amended time to time, the IRDA Act, 1999 and the
Regulations framed there under and that the contract will not commence until the Company's written acceptance of this Proposal Form is received. In case of the life to be insured
being a minor, I further declare and affirm that this proposal of insurance is for the benefit of the life to be insured.
Anti-Money Laundering Declaration: I hereby confirm that all premiums will be paid from bonafide sources and no premiums will be paid out of proceeds of crime related to any
of the offence listed in Prevention of Money Laundering Act, 2002. The Company has the right to peruse my financial profile and also agree that the Company has right to cancel
the insurance contract in case I have been found guilty of any of the provisions of any law, directly or indirectly, having relation to the laws governing prevention of money
laundering in the country, by any competent court of law.
I/We hereby understand that in accordance with the IRDAI (Protection of Policyholders' Interests) Regulations, 2017, the insurer is permitted to share policyholder information only
with the statutory authorities.
Applicable for NRI/PIO/OCI customers in case of assisted sales: I confirm that this product has been solicited to me in person in India or through email/ telephonic
communication from India. I undertake to inform the Company for any change in the above particulars including residential status. In case of any failure to do so, I shall indemnify
the Company for all losses and damages incurred by the Company due to non-fulfillment of my aforesaid obligation to the Company. I also undertake to comply with all the
regulations\ guidelines issued by Reserve Bank of India or any other regulatory authority with reference to NRIs/PIOs/ OCIs and the related insurance policies in India from time to
time.

Date: 12-03-2024
Place:

Signature/Thumb Impression of Proposer Signature/Thumb impression of Life Assured

I hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I undertake to inform you of any changes therein, immediately
in case any of the above information is found to be false or untrue or misstated, before issuance of the proposal. "I, the undersigned confirm that I have verified photocopies of the
proofs submitted along with this proposal form against the originals and certify the same to be true copy".
I declare and confirm that I have carried out necessary suitability analysis while advising this product to the proposer and that the product is suitable to the proposer.
WHERE THE PROPOSAL FORM IS FILLED IN BY AGENT/INTERMEDAIRY/EMPLOYEE:
I hereby declare that I have explained the contents of this proposal to the Proposer/Annuitants in the language known to him/her and ensured that the contents have been fully
understood by him/her. I have accurately recorded the Proposer/ Annuitant¿s responses to the information sought in the proposal form and I have read out the responses to the
Proposer/Annuitants and he/she has confirmed that they are correct

Signature of Agent/ Specified Person/ Broker/ Employee

 ACKNOWLEDGEMENT
Tear away portion (To be handed over to the customer)
Proposal Number: ___________________
Dear Customer
We acknowledge receipt of your Cash/Cheque/DD for Rs.______________ by number ______________ dated ___ /___ /___ drawn on _______________ toward¿ s Initial Deposit.
We request you to kindly verify the details filled in the proposal form before signing the same. Please do insist on Official Receipt issued by Tata AIA Life from your advisor within 2
working days from submission of this proposal form. In case you do not hear from us or do not receive your policy within 15 days/(4 days for PoS) from the date of submission of your
proposal, please visit us at www.tataaia.com or call our helpline number 1860 266 9966 (local charges apply) or email us at customercare@tataaia.com.
This is only acknowledgement slip and not the premium receipt.

Agent code Agent name Signature of Agent Date of Acknowledgement

 IN CASE OF THUMB IMPRESSION OF PROPOSER OR WHERE THE ANSWERS/SIGNATURE OF THE PROPOSER ARE IN VERNACULAR.
Note: The below must be declared by someone other than advisor/employee of the company.
I, _______________________________________ (name) have explained the contents of this proposal to the _________________________________________ (Proposer) in
____________________ (language) and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer responses to the information
sought in the proposal form and I have read out the responses to the Proposer and he/she has confirmed that they are correct.

Date: 12-03-2024
Place:

(Signature of the person making the declaration)

Address of the person making the declaration:

Declaration by Proposer:
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 Proposer Signature/Thumb impression of Life Assured

Date: 12-03-2024 Date: 12-03-2024

Place: Place:

(Prohibition of Rebates) Section 41 - of the Insurance Act, 1938 as amended from time to time: 1. No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the
commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as
may be allowed in accordance with the published prospectuses or tables of the insurer.
SECTION 45 OF THE INSURANCE ACT, 1938 STATES: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the
date of policy, i.e. from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is
later. A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of
revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that the insurer shall have to communicate in writing to the insured or
the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision is based. Nothing in this section shall prevent the insurer from
calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy adjusted on subsequent
proof that the age of the life insured was incorrectly stated in the proposal. For further details, please refer to the Insurance Act, as amended from time to time.

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

Full Form for abbreviations used: HUF ¿ Hindu Undivided Family | MWPA ¿ Married Women¿s Property Act | OCI ¿ Overseas Citizen of India | NRI ¿ Non-Residential Indian PIO ¿
Person of Indian Origin | FATCA - Foreign Account Tax Compliance Act | CRS ¿ Common Reporting Standard |CKYC ¿ Central Know Your Customer
Area census code is an identifier of the location as rural / urban as per the latest census.

L&C/Advt/2024/Jan/0176

1. Please do not handover cash to Agent. If handed over to the agent, the company will not be liable for any loss. 2. In case there is any change in the particulars given above including
Life Assured/Proposer's health and/or medical and/or financial and/or occupational status and/or being charged with and/or arrested for any criminal offence after the date of proposal
but before risk acceptance by the company; please inform the company. 3. Acceptance of premium does not constitute risk commencement. 4. Risk commencement starts after the
acceptance of risk by the company. 5. Free look Period: If you are not satisfied with the terms & conditions/features of the policy, you have the right to cancel the Policy by providing
written notice to the Company and receive the premiums after deducting a) Proportionate risk premium for the period on cover & b) Stamp duty and medical examination costs
including applicable taxes, cesses & levies, which have been incurred for issuing the Policy. Such notice must be signed by you and received directly by the Company within 15 days
from the date of receipt of the policy document by you or person authorized by you. The said period of 15 days shall stand extended to 30 days, if the policy sourced through distance
marketing mode which includes solicitation through any means of communication other than in person.

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.