Driver Questionnaire

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

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

1) Type of vehicle driven (Tick where applicable)

TYPE YES NO Approximate KMS/Day

CAR

BUS

TRUCK

CONTAINER

CRANE

OTHERS

2) If others, then please specify the type

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

3) Total distance covered in a day:

<100 kms 100-200 kms >200 kms

4) If Truck/Container, then, please specify whether carries (Tick where applicable)

Type of Goods carried YES NO

Hazardous/Explosive Goods

Non-Hazardous/Non-explosive Goods

5) Any history of accident while driving? If yes, please provide details with respect to severity of
accident and hospitalization/injury 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/Oct/280
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/Oct/280