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Occupation Questionnaire 1

The Occupation Questionnaire is a form for the proposed insured to provide detailed information about their job, including exact occupation, responsibilities, and time spent on various tasks. It also includes questions about job hazards, vehicle use, and a declaration of truthfulness regarding the provided information. The form is part of the life assurance proposal process with Tata AIA Life Insurance Company Limited.

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Nitesh
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96 views2 pages

Occupation Questionnaire 1

The Occupation Questionnaire is a form for the proposed insured to provide detailed information about their job, including exact occupation, responsibilities, and time spent on various tasks. It also includes questions about job hazards, vehicle use, and a declaration of truthfulness regarding the provided information. The form is part of the life assurance proposal process with Tata AIA Life Insurance Company Limited.

Uploaded by

Nitesh
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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Occupation Questionnaire

Name of Proposed Insured: ..........................................................................................................................

Policy no.: ...................................................................................... Dated:................................................

1) What is your exact occupation?


.......................................................................................................................................................

2) Job Responsibilities: Please describe your daily exact nature of duties in details
........................................................................................................................................................

3) How long have you been engaged in your occupation?


.........................................................................................................................................................

4) What percentage of your working time is spent on the following?


Administration % Supervisor %
Manual Labour % Travel %

5) Job Nature (Tick as appropriate). If Yes, please mention details below.


□ Indoor / Outdoor
□ Operation of Machine/No Operation of Machine
□ Work at heights/No work at heights
□ Work offshore or underground/No work offshore or underground
□ You had any accidents or illness associated with your duties?

.......................................................................................................................................................

6) Do you drive a vehicle or ride a motorcycle as part of your job? Yes No


(Other than travelling to and from your normal place of work)?
If so how many kilometers per day? ............................Km/day

7) Do you consider your occupation to be hazardous in any way? Yes No


(For example dealing with explosives or chemicals, working with
high voltages or extreme heat furnaces).
If Yes, please provide details: .......................................................................................................

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/237
I declare that the answers I have given are, to the best of my knowledge, true and I have not withheld any
material information that may influence the assessment of acceptance of this proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to disclose any
material fact known to me may invalidate the contract.

Signature of Proposed insured:______________________ Date:____________________

Signature of Applicant:______________________ Date:____________________


(If applicant is different from the proposed insured)

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

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/237

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