TataAIA/NB/DM/126

Residence and Travel Questionnaire

Proposal No: C223595208 Name of Life Assured: ARVIND TEMBHURNE

1. Please provide details of your current residency and residential status including information of
duration of stay.
Current Residency – INDIA, Current residential status – Indian resident with Indian citizenship. Staying in India since birth.

_ _
2. Please provide details of your previous and future residence and travel:
Previous residence and travel (in the last 12 months)
Dates of Country and Reason for Frequency Duration of each
Stay/ Travel Region Visiting (number of Stay/ Travel
of residence/ trips per year)
travel
12/12/2019 to United Status, Business trip One 3 days
16/12/2019 Chicago Illinois

Future residence and travel intentions (in the next 12 months)

Dates of Country and Reason for Frequency Duration of each
Stay/ Travel Region Visiting (number of Stay/ Travel
of residence/ trips per year)
travel
Proposed in August United Status, Job Reallocation One 2 to 5 years
2019 Chicago Illinois

3. Please provide a brief description of your occupational duties and/ or any other activities you
will participate in while traveling or residing abroad.
I will be employed in USA as a finance professional mostly on the desk job work.
4. Do you expect to spend the majority of your time in major / large cities? Yes No
If No, please provide the name of the town/ region and details of your likely accommodation,
availability of medical facilities and travel arrangements (e.g. light aircraft, boat etc.):
Chicago Illinois, United States

5. Please give details of any medical treatment or surgery undergone by you while residing
overseas.
None

6. Please provide any additional information regarding your residence and travel which you feel
may be relevant to / helpful in processing your application.
I might also do my Master of Business Management from US university

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 a 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: ARVIND TEMBHURNE Date: 11/04/2020

Signature of Applicant: ARVIND TEMBHURNE _ Date: 11/04/2020
(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) or write to us at customercare@tataaia.com . Visit us at www.tataaia.com or SMS “LIFE” at
58888 Unique Reference Number L&C/Misc/2020/Mar/082