Alcohol Usage Customer Questionnaire

Name of Proposed Insured: _____________________________________________

Application No: ------------------------------ Application Date: -------------- (MM/DD/YY)

Questions Please give full and accurate answers to each

Question. Use an additional sheet if necessary.

1. At what age did you first start to

Consume alcohol?

2. Please state the current amount and

Type of alcohol consumed per week.

3. what were your past habits as regards

the consumption of alcohol? (state
type of alcoholic liquor consumed
and amounts per week and give dates).

4. Have you ever been advised to reduce If ‘yes’, Please provide details.
or discontinue you alcohol intake?

5. Have you ever been referred for If ‘yes’, Please provide details.
Counseling or treatment, hospitalised
or attended a clinic due to your
alcohol consumption?

6. Have you ever received medical If ‘yes’, Please provide details.

Treatment for excessive consumption
of alcohol?

7. Have you had any blood or other If ‘yes’, Please provide details.
Tests related to your alcohol consumption?

8. Have you consulted a doctor or If ‘yes’, Please provide details.

Received medical advice or treatment
Within the past years with reference
To liver disease, heart disease or
Blackouts?

9. Have you ever been involved in any If ‘yes’, Please provide details.
Breach of the law, including traffic
Offences, in connection with the use
of alcohol?

Tata AIA Life Insurance Company Limited

Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013
For more Information, call on our Helpline No’s 1-800-267-9966 (toll free) or at 1-860-266-9966 (local charges apply).
10. How long have you been in your present If less than 5 years, please give details?
Employment? of previous occupations.

11. Please state any further relevant

Particulars which may have had
Bearing on any past or present
Increase in alcohol consumption, e.g.
Domestic or business upset.

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 on my life. I
also authorize the company to obtain, if necessary, confidential reports from any
doctor/clinic/hospital that I have referred above.

Date: ______________ Signature of Proposed Insured: _________________

(If proposed Insured is under age 18, signature of

Applicant is required)

Tata AIA Life Insurance Company Limited

Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013
For more Information, call on our Helpline No’s 1-800-267-9966 (toll free) or at 1-860-266-9966 (local charges apply).