Tata AIG Accident Guard Form

Accident Guard Personal Accident Plan Proposal Form

Proposal No.

Personal Details (In block letters)

Self

Name of the Insured

Address

City    State    PIN

Phone (O)    (R)

Fax    Mobile

E-mail

Date of birth    Marital Status

Sex   Male   Female

Occupation   Service   Self Employed

Nominee’s Name*

Relationship

* In case the nominee is a minor, please provide the name of the guardian also.

Family

Name of Spouse

Nominee Name*

Relationship    Date of Birth

Name of First Child

Nominee Name*

Relationship    Date of Birth

Name of Second Child

Nominee Name*

Relationship    Date of Birth

Name of Third Child

Nominee Name*

Relationship    Date of Birth

Name of Fourth Child

Nominee Name*

Relationship    Date of Birth

* In case the nominee is a minor, please provide the name of the guardian also.

Policy Details (Please tick below)

Policy Period : From   To

Benefits

Core Benefit (up to 20)
Plan A Self Family   Cost/Unit   No. of Units   Total Annual Premium

Plan B
Self Family   Cost/Unit   No. of Units   Total Annual Premium

Optional Benefit
Accidental Weekly Benefit   Cost/Unit   No. of Units   Total Annual Premium

Grand Total

Additional Details

1) Whether you are suffering/met with any illness/injury/disability in the last 2 years : Yes No

If Yes, provide details :

2) Whether you have taken any personal accident policy. Yes No

If yes whether from Tata AIG Other (Please Specify Name)

Policy No.

Other details:

3) I hereby declare that my Gross Annual Income is ( Rs '000):   and understand that the Sum Insured opted for will not be greater than 10 times / 20 times Gross Annual Income as applicable.

Payment Details

Premium Amount: Rs.   Cheque   Demand Draft

Cheque/Demand Draft No.:   Date:

Name of Bank:   Branch:

Credit Card*

Credit Card No.:   Expiry Date:

Transaction Code

**For credit card payment: 1) Only Visa/Master Card accepted. 2) Photocopy of front and back of the credit card has to be attached along with the application form.

PAN card Number :   in the absence of PAN Card, please give details of any other authorized photo identification card.

Card Type   Number :

Sources of funds (please ü where applicable) : Salary Business Other (Please specify)

Signature Section

This Policy does not cover pre-existing medical conditions that are declared or undeclared. In the event of a claim, in order to determine eligibility for benefit payments under the Policy. I/We authorize any hospital, medical care institution, physician, medical professional, pharmacy or insurers to furnish to Tata AIG General Insurance Company Limited or its representatives any and all medical information or records with respect to any injury or sickness suffered by the person whose, death, injury, sickness or loss is the basis of a claim against the Policy. I/We understand that this authorization is valid during the pendency of the claim until all issues with regard thereto have been definitively resolved, either extra-judicially or judicially. I/We have read the Policy Prospectus and am/are willing to accept the insurance coverage, subject to all the terms, conditions and exceptions described in that Policy Prospectus. I/We hereby declare and warrant that all of the statements in this and in the preceding paragraphs are true and complete. If it is found that the answers or particulars stated in this Proposal Form and Medical Declaration are incorrect or untrue in any respect, I/We hereby acknowledge that the insurance company shall incur no liability for any insurance coverage. I/We have understood the term & conditions of this insurance and agree that the insurance would be effective only on acceptance of this application by the Company and the payment of premium by me/us in advance.

AML Guidelines: I/we herby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related to any of the offence listed in Prevention of Money Laundering Act, 2002. I understand that the Company has the right to call for documents to establish sources of funds. The insurance company has right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statutes, directly or indirectly governing the prevention of money laundering in India.

INSURANCE ACT 1938 Section 41 Prohibition of Rebates: 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 prospectus or tables of the Insurer.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.