Accident or Injury Questionnaire

Name Of Proposed Insured: ............................................................................................................................

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

1) Date of injury or accident? .......................................................

2) How did the accident or injury occur?

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

3) Date you last attended the doctor for this condition? ......................................................

4) Do you still receive treatment or suffer any symptoms?( Have you fully recovered from your
injuries? )
.............................................................................................................................................................

5) Describe the nature of the injury (specify the part affected) and treatment given (name/type
and dosage.)
.................................................................................................................................................

6) Did you require more than two weeks away from your usual occupation?
............................................................................................................................................................

7) Were you admitted to hospital? If Yes, for how long?

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

8) Have you lost any limb/limbs or part of it due to the accident or injury? If Yes, are you using any
prosthesis for the lost part?
..............................................................................................................................................................

9) Have you ever smoked cigarettes or any form of tobacco in last 2 years, If Yes, how much do you
smoke? If now stopped, advise since when?
...........................................................................................................................................................

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/253
I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.

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/253