ay WAV Wea Agi ulture Questionnaire ee OCR on Application Number: Name of Namo Life io be heured / Proposer vee LL | A. Deal of tad holding 4. Whereis the Land stro a Place: | b. Suey No/ age | «. Daviet | 4 sae I ‘ Total Lard ure cuvaon InAs aes Ba Tas BOs h oly Onned by you|_] Jonty Owned byyou |] Land not owrad tt Only Cute by youl] 6. Lan ey Onna Yu lease ro th fonda dea Face Sh of Lard owed by ou (epee ora) TholSrr owed you Nao Owen oft Lard Falter wih he shred Land Oona 1h Land rot ured by you but ony Gullated by your (Passe pose buow rae a wouter and wba wont docurerti alee): Ary pro sharingbase ‘agyoement Land is nat owned but fring is ony culate by YOU! B, Details of Crops / Fruits / Vegetables grown: Sr Crop Name Trea under | Season of crop grows | No. of tmnes the | Vield of Grop | Market Value of No cultivation ‘crop is grown Quintal in the Crop (1 Quintal = 100K) | (eer guint) C. Details of Cutvation = ‘Since now mary years the land is undor cultivation? oars 2. ‘Type ol igation used for farming (example: Wel water iigaton, Tank water ingaton, Canal rigation, Perennial Canal rigation ete.) 3, oes the land under cutvation has contruous water sueph 42. Has there boen any droughtsloeds/any other natural calamities in the ast 3 years which has alfected your yl?” 5. Doyousel he produce decty to Goverment or Private Pubes Compary:|_|¥es. |_]No ifyes, plaase provide deals ofthe orgarzaton / department Stas: Ll | 6, Where do you sel te agneukwral produce? Prokie ae o APNE market Wand / Open rare Go oparave sky opasa houses / oor a) Ll | Provide the name, access of he cormisson agent / purchase ofthe produce 8 Doyourie: nome tax |_|Yee/|_JNO Weathtax|_|Yes/|_JNO Property tx|_|Yes/_]NO 9. _Anyother source of income apa fom te acute? I, please ge ets 10. Do you hold Beow the povery ine ration card Fay ea? [_]¥es/[_]NO +1. Whether you or your fay are avaing any subary tenets pide by the povernmant Ll | 12,_Plase provi te flowing datas: ( eget | (Such as Tractor, Harvesting machines otc.) Details of Livestock | (Farm animals ke cate, sheep etc)TATA AIA LIFE INSURANCE COMPANY LIMITED D. 1. Bank Account Details: Name of Bark ‘Bank Account Number ‘Account Opening Date D. 2, Details of Agricultural Loan : Name of Bank /institution ‘Amount oF Loan opted 7 uation of the Lean years/months Frequency of Payment (an Ha Voor, Guim Mah Outstanding Amount 7 . Please mention your total gross annual income forthe last 3 years. In case of profit sharing arrangement please mention amount of your share of profit made for the last three years: Year ‘Annual home earned) Signatur of Lie Insured / Proposer] Date: | fy Lv Place: (VERNACULAR DECLARATION: (in case Life Insured/Proposer signs in Vernacular Language / Thum impression) |_—_______hotaing _____ 0 cart ype} with namber__ 0 Gard ruber) ners deca that have expained the contents of tis declaration tothe Proposed InsurediReplcant in language and thatthe Proposed Insured /Appicant nas affxed niger signaturethumb impression after uly understanding the contents thereof ‘Slgnalura/Thunb rrpression of Witness Sionature Life InsurecProposer Date] [milly Ly Ly Place: Kina provide 7/12 Extract OR. Land Records alongwith Form J/Mand! reodipl/Palwarl Book/Tehsidar carcate ete. as a supportive document alongwith Agrcuture Questonnare Webste: wor tataaa.com- Halpin Nos 1-600-267-8066 al) 1-860-266-0968 focal cheges app 2a: customercareOtataaa.com StS “SERVICE” o 58888 “Tata AIA Life Insurance Company Ltd. (RDA of nda Rogn. No. 110 » CIN. UB60OVFZ000°L0 728408) Registered & Corporate Office Address: Floor, Tower A, Penesda Business Park Sonapai Bapat Mag, Lower Par, Mamba £00013, For more detals on sk factors, tems & condons please read sales brochures careull before concluding a sale. + LACIIMi/2016/Mar/100 ‘BEWARE OF SPURIOUS PHONE GALLS AND FICTITIOUS/FRAUDULENT OFFERS IRDA of inca clarifies to publ that IRDA of India or its officials do not involve in activites lke sale of any kind of insurance or financial products nor invest promis. = IRDA of India does not announce ary bonus. Pubic receling such phone cals are requested to lodge a palce compant along wih detais of hone cal number,