Term Gautam

Gautam Pratyush
#RakshakaranKiReet 1/49
IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.
, ,
MU01 U242922179 SP 2151/2166 BROK Non Term_EIA

Gautam Pratyush
S/O SANJAY KUMAR NAYA TOLA, KUMHARAR, November 22, 2023
CHANAKY
A NAGAR NEAR ASHOK KUMAR SINGH HOUSE
BEHIND LALITA RAJ APPARTMENT
PATNA 800026
BIHAR INDIA
M- 9199878315
Dear Policyholder,
Congratulations on becoming your family’s Param Rakshakarta !!
Today, protection is the need of the hour and we are privileged that you have chosen us as your Rakshakaran partner. We are
delighted that you have opted for one of our comprehensive solutions that will provide Life Cover as well as market-linked returns
and protection for your health – helping you secure your loved ones’ financial future.
The comprehensive solutions will provide following benefits:
Comprises of Tata AIA Life Insurance Smart Sampoorna Comprises of Tata AIA Life Insurance Smart Sampoorna
Raksha, Tata AIA Life Insurance Comprehensive Protection Raksha and Tata AIA Life Insurance Comprehensive
Rider and Tata AIA Life Insurance Comprehensive Health Rider Protection Rider
Life Insurance Cover Life Insurance Cover
Accidental Death Benefit Accidental Death Benefit
Accidental Total & Permanent Disability Benefit Accidental Total & Permanent Disability Benefit
Criticare Plus Benefit
Hospicare Benefit
All in all, these solutions will cater to your protection, wealth and health protection needs.
At Tata AIA Life Insurance, we are committed to help you with solutions that will provide Param Rakshakaran to your family so
that you can enjoy life without any worries.
Best Wishes
Tata AIA Life Insurance Company Limited
Disclaimers: Param Rakshak solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha, A Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and
Protection (UIN:110L156V02) and Tata AIA Life Insurance Linked Comprehensive Protection Rider, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A032V02) and
Param Rakshak Plus solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha, A Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and Protection
(UIN:110L156V02), Tata AIA Life Insurance Linked Comprehensive Protection Rider, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A032V02) and Tata AIA Life
Insurance Linked Comprehensive Health Rider, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A031V02). For more details please refer to the customized benefit
illustration and terms & conditions of the product. In case of any inconsistency between this letter and policy document, the policy document shall always prevail.
2/49
, ,
Gautam Pratyush
CHANAKY
PATNA 800026
BIHAR INDIA
M- 9199878315
Dear Gautam Pratyush ,
Thank you for choosing us to protect your loved ones.
Your decision to select Param Rakshak with return of rider premiums with a Life Cover of 1,50,00,000 will help secure
the financial future of your loved ones as it comprises Tata AIA Life Insurance's
Smart Sampoorna Raksha, Accidental Death and Accidental Total & Permanent Disability, under Tata AIA Vitality
Protect Plus.
This solution also offers a holistic wellness program-Tata AIA Vitality - which partners with you to help you focus on
your physical and mental wellbeing while keeping you motivated with various discounts and benefits.
Tata AIA Vitality - A Wellness Program that offers you an upfront discount at policy inception. You can also earn
premium discount / cover booster (as applicable) for subsequent years on policy anniversary basis your Vitality Status
(tracked on Vitality app).
In case of death during the Policy Term, you are entitled to a life cover of 1,50,00,000 under the base plan (Tata AIA
Life Insurance Smart Sampoorna Raksha). In case of no claims during policy term, total premiums paid with respect to
Accidental Death and Accidental Total & Permanent Disability, will be returned to you at Maturity.
Kindly refer to our benefit illustration here for all requisite details.
At Tata AIA Life Insurance, we are committed to help you live happier, healthier lives through solutions that provide
Sampoorna Rakshakaran to your family so that you can be happy, with no worries.
Best Wishes
Naveen Tahilyani
CEO & Managing Director
Authorised Signatory
Disclaimer: Param Rakshak ROP solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha, A Unit-linked, Non-participating, Individual Life Insurance Plan
for Savings and Protection (UIN: 110L156V03) and Tata AIA Vitality Protect Plus, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A048V01).
Insurance cover is available under the solution. | The solution is underwritten by Tata AIA Life Insurance Company Ltd. This is not a guaranteed issuance solution and it
will be subject to Company's underwriting and acceptance. | For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a
sale.
THE LINKED INSURANCE PRODUCT DO NOT OFFER ANY LIQUIDITY DURING THE FIRST FIVE YEARS OF THE CONTRACT. THE POLICY
HOLDER WILL NOT BE ABLE TO SURRENDER/WITHDRAW THE MONIES INVESTED IN LINKED INSURANCE PRODUCTS COMPLETELY OR
PARTIALLY TILL THE END OF THE FIFTH YEAR.
L&C/Misc/2023/Sep/0469
Policy Servicing Branch : 101-Boston house,Suren Road,Nr, Western Highway,Andheri E - 400093

Tata AIA Life Insurance Company Ltd (IRDA of India Regn.No.110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
#RakshakaranKiReet Go to Table of Contents 3/49

, ,
Gautam Pratyush
CHANAKY
PATNA 800026
BIHAR INDIA
M- 9199878315
1. Part A
Dear Gautam Pratyush,
Thank you for choosing us for your insurance needs. Tata AIA Life is committed to give you world-class products and professional
service.
We take great pleasure in presenting your Policy Document. Please check your personal details and the policy provisions carefully.
Should you have any queries, please contact your agent or contact us at the address mentioned below. You can also reach us via
email at customercare@tataaia.com or call our helpline number at 1860-266-9966 (Call charges apply).
In order to provide You better services, We request you to intimate us in the event of any change in the address of the Policyholder
or the nominee.
Free Look Provisions
If the Policyholder is not satisfied with the terms & conditions, he/she can cancel the Policy by giving written notice to the
Company and receive the non-allocated Premium plus charges levied by cancellation of Units plus Fund Value at the date of
cancellation less (a) proportionate risk Premium for the period of cover (b) medical examination costs, if any and (c) stamp duty,
along with taxes on above which has been incurred for issuing the Policy. Such notice must be signed by the Policyholder and
received directly by the Company within 15 days after receipt of the Policy. The said period of 15 days shall stand extended to 30
days, if the Policy is sourced through distance marketing mode.
Distance Marketing includes every activity of solicitation (including lead generation) and sale of insurance products through voice
mode, SMS electronic mode, physical mode (like postal mail) or any other means of communication other than in person.
The applicable free look period for this Policy shall be 30 days from the date of receipt of the policy document.
You may be eligible to avail the Health Management Services as per Clause 4.1 of Part C.
At Tata AIA Life, we believe that life inspires us to think ahead. Our insurance solutions are therefore designed to be a stepahead,
thus giving you an advantage to adapt to tomorrow’s changes, starting today.
We look forward to a long and cherished relationship with you. ¬nn¬-Hrj¡¤WfqTi¬14-¬nn¬
Best wishes,
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/e7.CL£Aj0fn©jK8{}QY0|y.K j
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Naveen Tahilyani
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Scan the QR to download e-policy document
CLICK HERE TO READ THE TERMS AND CONDITIONS


"Stamp duty of Rs. 4000 is paid as provided under Article 47(C)/(D) of Indian Stamp Act, 1899 and included in Consolidated
Stamp duty paid to the Government of Maharashtra Treasury vide order of Addl. Controller of Stamps, Mumbai at General Stamp
office, Fort, Mumbai – 400001 vide his order No. LOA/CSD/04/2023/4270 / Date 25/10/2023 / Validity period Dt.
28/10/2023 to Dt. 30/04/2024"
(Signature)
Proper Officer
Tata AIA Life Insurance Smart Sampoorna Raksha (UIN: 110L156V03)

Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and Protection
In this policy, the Investment risk in Investment portfolio is borne by the Policyholder
LIFE INSURED Gautam Pratyush

POLICY NUMBER U242922179
PREAMBLE
Tata AIA Life Insurance Company Limited (“the Company”), having received a Proposal form and other related documents with
Declaration thereto and initial premium from the Policyholder hereby issues Tata AIA Life Insurance Smart Sampoorna
Raksha, a Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and Protection plan. The Company under
this Policy; does agree in consideration and subject to Policy conditions to pay the benefits under the Policy on the happening of
an Insured event, while the Policy is in force. The basic insurance plan provided under this Policy, with its amount of coverage
and Premium is specified on the Policy Schedule. Entitlement to benefits, conditions for payment and other policy details are
also set out inside. This Policy is subject to terms and conditions motioned herein below and endorsements if any.
Signature valid
Signed by: Naveen Tahilyani
Date:
Location:
This is a system generated document requiring no physical signature.

, ,
Gautam Pratyush
CHANAKY
PATNA 800026
BIHAR INDIA
M- 9199878315
Tata AIA Vitality Protect Plus (UIN: 110A048V02)

Linked, Non-participating Individual Health Rider
1. Part A
Thank you for choosing us for your insurance needs. Tata AIA is committed to give you world-class products and professional
service. We take great pleasure in presenting your Rider Pack for our Tata AIA Vitality Protect Plus, a Non-linked,
Non-participating Individual Health Rider. Please check your personal details and the rider provisions carefully. Should you have
any queries, please contact your agent or contact us at the address mentioned below. You can also reach us via email at
customercare@tataaia.com or call our helpline number 1860-266-9966 (Call charges apply).
In order to provide better service, We request you to intimate us in the event of any change in the address of the Policyholder or
the nominee.
You have a free look period of 15 days from the date of receipt of the Rider document and period of 30 days in case of Rider
obtained electronic or distance mode, to review the terms and conditions of the Rider. If You disagree to any of those terms or
conditions, You have the option to return the Rider document for cancellation of the benefit option, stating the reasons for
objection and be entitled to a refund of the premiums paid, for the benefit option, without interest after deduction of proportionate
risk premium, stamp duty and medical examination cost along with applicable taxes and cesses or levies, if any.
The applicable free look period for this Policy/Rider shall be 30 days from the date of receipt of the Policy Pack.
You may be eligible for Health Management Services as detailed under Clause 3.3.1 of the Part C.
On examination of the Policy Pack, if you notice any mistake, please return the Policy Pack to the Company immediately for
correction.
At Tata AIA Life we believe that life inspires us to think ahead. Our insurance solutions are therefore designed to be a step ahead,
thus giving you an advantage to adapt to tomorrow’s changes, starting today.
We look forward to a long and cherished relationship with you.
Best wishes,
Naveen Tahilyani


"Stamp duty of Rs. 4000 is paid as provided under Article 47(C)/(D) of Indian Stamp Act, 1899 and included in Consolidated
Stamp duty paid to the Government of Maharashtra Treasury vide order of Addl. Controller of Stamps, Mumbai at General Stamp
office, Fort, Mumbai – 400001 vide his order No. LOA/CSD/04/2023/4270 / Date 25/10/2023 / Validity period Dt.
28/10/2023 to Dt. 30/04/2024"
(Signature)
Proper Officer
Tata AIA Vitality Protect Plus (UIN: 110A048V02)

INSURED Gautam Pratyush

RIDER NUMBER U242922179
PREAMBLE
Tata AIA Life Insurance Company Limited has entered into this contract of insurance on the basis of the information given in the
Proposal Form together with the premium deposit, statements, reports or other documents and declarations received from or on
behalf of the proposer for effecting a life insurance contract on the life of the person named in the Schedule below.
We agree to pay the benefits under the Rider on the happening of the insured event, while the Policy and Rider are in force
subject to the terms and conditions stated herein.
Signature valid
Signed by: Naveen Tahilyani
Date:
Location:
This is a system generated document requiring no physical signature.
CLICK HERE TO READ TERMS AND CONDITIONS

OF VITALITY PROTECTION RIDER

TABLE OF CONTENTS
Section Description Page No.
Policy schedule Detailed overview of your registered policy 9
List of the beneficial features that comprise

Key feature document 13
your plan
Range of customer-centric services offered by

Service options 22
Tata AIA Life Insurance
A pre-investment, agreed-upon form that

Proposal Form 26
proposes the details of your policy
An illustrative way of presenting year-wise

Benefit illustration premiums payable and benefits under the 26
policy
Record of all transactions that occur with the

Unit Statement 47
funds in your ULIP investment
Acknowledgement of the first premium

First premium receipt 49
payment

POLICY SCHEDULE
THIS SCHEDULE MUST BE READ WITH THE POLICY DOCUMENT AND IS PART OF
THE LIFE INSURANCE CONTRACT
Policy Number: U242922179
Policyholder Details Policyholder Life Assured
Name Gautam Pratyush Gautam Pratyush
S/O SANJAY KUMAR NAYA TOLA, KUMHARAR, S/O SANJAY KUMAR NAYA TOLA,
CHANAKY KUMHARAR, CHANAKY
A NAGAR NEAR ASHOK KUMAR SINGH HOUSE A NAGAR NEAR ASHOK KUMAR SINGH
BEHIND LALITA RAJ APPARTMENT HOUSE
Address
PATNA BEHIND LALITA RAJ APPARTMENT
800026 PATNA
BIHAR INDIA 800026
BIHAR INDIA
Client ID 376552624 376552624
Date of Birth 15/10/1999 15/10/1999
Age at entry 24 years 24 years
Age Admitted Yes Yes
Gender Male Male
Date of Date of Annualised
Basic Sum Date of Maturity Policy Term
Base Plan/Rider Name commencement of commencement Premium (Excl.
Assured (Rs.) of Policy (Years)
policy of Risk taxes) (Rs.)
Tata AIA Life Insurance Smart
Sampoorna Raksha
(UIN: 110L156V03), Unit-linked,
1,50,00,000.00 18/11/2023 18/11/2023 18/11/2063 1,02,041.00 40
Non-participating, Individual Life
Insurance Plan for Savings and
Protection
Please refer to Schedule Page 2 for additional rider details
Modal Total Modal

Mode of Premium Due Date of Premium Applicable
Premium Premium Premium
Base Plan/Rider Name Premium Paying Last Premium (Excl. taxes) taxes, cesses &
Due Date (s) (Incl. taxes) (Incl. taxes)
Payment Term(Years) Payment (Rs.) levies (Rs.)
(Rs.) (Rs.)
Sampoorna Raksha
(UIN: 110L156V03), Unit-linked,
Monthly 5 18/12/2023 18/10/2028 8,500.00 .00 8,500 11,340.00
Non-participating, Individual Life
Insurance Plan for Savings and
Protection
Please refer Schedule Page 2 for additional rider details
Benefits payable
Maturity Benefit As per Clause 3.1 of Part C of policy document
Death Benefit As per Clause 3.2 of Part C of policy document
Applicable Target Gross Reduction-in-Yield (TGRIY)

Policy Year TGRIY Policy Year TGRIY Policy Year TGRIY Policy Year TGRIY Policy Year TGRIY
1 13.59 9 11.59 17 9.59 25 7.59 33 5.59
2 13.34 10 11.34 18 9.34 26 7.34 34 5.34
3 13.09 11 11.09 19 9.09 27 7.09 35 5.09
4 12.84 12 10.84 20 8.84 28 6.84 36 4.84
5 12.59 13 10.59 21 8.59 29 6.59 37 4.59
6 12.34 14 10.34 22 8.34 30 6.34 38 4.34
7 12.09 15 10.09 23 8.09 31 6.09 39 4.09
8 11.84 16 9.84 24 7.84 32 5.84 40 3.84
Nominee details (under section 39 of the Insurance Act 1938)

Name of the Nominee (s) Relationship with Life Assured Gender Age Nomination %
VINITA KUMARI Mother Female 46 100.00
Appointee details (Applicable in case the Nominee is a minor)

Name of the Appointee (s) Relationship with Nominee Gender Age (years)
NA NA NA NA
On examination of the Policy, if you notice any mistake, please return the Policy to the Company immediately for correction.

POLICY SCHEDULE
THIS SCHEDULE MUST BE READ WITH THE POLICY DOCUMENT AND IS PART OF
THE LIFE INSURANCE CONTRACT
Agent/Intermediary Name Agency/Intermediary Code Agent/Intermediary Contact details

POLICYBAZAAR INSURANCE BROKERS PRIVATE
004665695 18002585970 / care@policybazaar.com
LIMITED
On examination of the Policy, if you notice any mistake, please return the Policy to the Company immediately for correction.

SCHEDULE
Tata AIA Vitality Protect Plus (UIN:110A048V02)
Accidental Total &

Benefit Option Accidental Death
Permanent Disability
UIN 110A048V02 110A048V02

Life Insured Name Gautam Pratyush Gautam Pratyush
Address as per proposal form as per proposal form
Client ID 376552624 376552624
DOB 15/10/1999 15/10/1999
Age at entry (Years) 24 24
Age Admitted Y Y
Gender Male Male
Sum Assured under
50,00,000 50,00,000
Benefit Option (Rs.)
Benefit Payout Option Lumpsum Lumpsum
Lumpsum (Rs.) 50,00,000 50,00,000
Income p.a. (Rs.) NA NA
Income Duration (Years) NA NA
Return of Balance
Yes Yes
premium option
Tata AIA Vitality
Y Y
(Wellness Program)
Utilization of Rewards
Premium Discount Premium Discount
during PPT
Coverage Term (Years) 40 40
Premium Payment Term
5 5
(PPT) (Years)
Date of Commencement
18/11/2023 18/11/2023
of Risk
Due Date of Last
18/10/2028 18/10/2028
Premium Payment
Maturity/Expiry Date 18/11/2063 18/11/2063
Annualised Premium
12,100.00 16,600.00
(Excl taxes) (Rs.)
Modal Premium
1,015.00 1,392.00
(Excl taxes) (Rs.)
Tax, Surcharge and
183.00 251.00
Cess (Rs.)
Total Modal Premium for
first year (Incl taxes and
1,198.00 1,643.00
discounts, if applicable)
(Rs.)
Total Modal Premium
1189.35 1631.68
(Incl taxes) (Rs.)
Details of Nominee (not applicable if Benefit Payout Option is Partner Care)

As per Base Plan
Details of Partner (applicable only if Benefit Payout Option is Partner Care)

Benefit Option Relationship with Rider Life
Name of Rider Life Insured Name of Partner DOB of Partner Gender Percentage
in Part C Insured
Note: This schedule must be read with the accompanying policy document and is part of the life insurance contract.
Discount applicable and Modal Premium payable 2nd year onwards will depend on the Wellness status of the Insured
#RakshakaranKiReet
Go to Table of Contents 11/49
OTHER ENDORSEMENT

KEY FEATURE DOCUMENT
This is a Unit-Linked, Non-participating, Individual Life Insurance
Savings Plan for Savings and Protection.
Benefits you've opted for under the plan

Market-Linked Returns Choice of Fund Options
See your investment grow with potential Flexibility to choose from range of fund options
market linked returns and loyalty additions. for enhanced investment opportunities
Life Cover
Enjoy life cover throughout the policy term
You will receive Total fund value which is the sum of Regular/Single Premium Fund
Maturity Benefit Value and Top-up Premium Fund Value at applicable NAV as on date of Maturity.
Death Benefit
In case of death of the life insured during the policy term and while the policy is in force, the claimant heir will get, highest of
(i) the Basic Sum Assured net of all “Deductible Partial Withdrawals”, if any, from the Regular/Single Premium Fund Value, or
(ii) the Regular / Single Premium Fund Value of this Policy or
(iii) 105 percent of the total Regular/Single Premiums paid up to the date of death.
In addition to this: Highest of
(i) the approved Top-up Sum Assured(s) or
(ii) Top-up Premium Fund Value of this Policy or
(iii) 105 percent of the total Top-up Premiums paid up to the date of death
Loyalty Additions
Refund of 2X Mortality Charges Refund of 2X Premium Cover Continuance Booster -
Allocation Charges -
Starting from the 11th Policy Year, two times At the end of 10th, 11th, 12th and 13th Non-negative amounts shall be added in form of
the monthly mortality charge (excluding Policy Years, two (2) times the total addition of units at the end of Policy Month if Fund
underwriting extra and taxes) deducted during Premium Allocation Charges (excluding Value falls below 10% of the Modal Premium during
the period of 120 preceding Policy Month shall taxes), deducted over the Policy Years 1, 2, First 15th Policy Years and at the end of each Policy
be added to the Fund Value at the end of each 3 and 4 respectively, shall be added to the Month if Fund Value falls below Fund Value implied
Policy Month in the form of addition of units. Fund Value in the form of addition of units. by the Target Net Yield from 16th Policy Year till the
end of Policy Term
Grace Period Waiting Period

Monthly Mode: 15 days | Other Modes: 30 days Not Applicable
Exclusion
In case of death due to suicide within 12 months from the date of commencement of the policy or from the date of revival of the
policy, the nominee or beneficiary of the policyholder shall be entitled to fund value/policy account value, as available on the date
of intimation of death. Any charges other than Fund Management charges recovered subsequent to the date of death shall be
paid-back to the nominee or beneficiary along with death benefit
Riders The detailed provisions of the rider if availed, are available in the terms and conditions.
Stay invested in your plan and get the best growth for a secure financial future

A holistic wellness program by Tata AIA Life Insurance
Be Healthier, Happier, Everyday!

A science-based, personalised wellness program that helps you keep
track of your progress towards a healthier, happier you and rewards
you for making better choices. The Vitality app is your partner in your
journey towards your holistic wellbeing.
Know Your Health Improve Your Health
Take health checkups Improve it through physical

and assessment activities and daily challenges
Online Assessments Maximum

and Description annual points
Vitality Health Review 1,000

Know your Vitality age or
Vitality Nutrition Assessment 1,000

Assess your eating habits Daily Points Steps Heart Rate
Non-Smoker Declaration 1,000

Commit to a healthy behavior 30 minutes of physical
activity at >=60% of
50 7,500 - 9,999 age-related maximum
Vitality Sleep Quality Survey
300 heart rate*
Evaluate your mental health
30 minutes of physical
activity at >=70% of
Vitality Mental Health Survey
300 100 10000+ age-related maximum
heart rate*
OR
60 minutes of physical
Vitality Resilience Survey
300 activity at >=60% related
maximum heart rate*
Vitality Health Check

12,000
Vitality Health Check
*Age-related maximum heart rate = 220 – Current Age
15,900 Points Annually Additional 15,000 Points Annually

Im
th p
al
ro
rh
ve
you
you
Know
r health
A holistic wellness program by
ONLINE
ASSESSMENT
OF YOUR VITAL `
STATS
E nj
o y t h e re w a rd s
Get Rewarded
Opting for Vitality provides you an upfront discount on your first year premium. You start at
Bronze status with zero points. Earn points through the various activities in the ‘Know your
health’ and ‘Improve your health’ sections and move up the ladder to Platinum status.
Vitality Status Vitality Points Benefit Category 1* Benefit Category 2*
Upfront Discount 5.00% 10.00%
BRONZE
0 -2.50% -5.00%
SILVER
10,000 -1.25% -2.50%
Renewal Discount
Calculation GOLD
20,000 0.50% 1.00%
PLATINUM
25,000 1.00% 2.00%
Max Discounts 15.00% 30.00%
Example - Basis completion of activities mentioned in “Know Your Health” and “Improve Your Health” sections of the Vitality App, the
customer would attain the status of Bronze, Silver, Gold or Platinum.
For Platinum status, the total discount applicable would be 12% i.e., 10% (discount applicable previous year) + 2% (Status based discount)
for Benefit Category 2 Riders. Similarly, for Benefit Category 1 Riders, the discount would be 6%.
For Silver status, the total discount applicable would be 7.5% i.e., 10% (discount applicable previous year) – 2.5% (Status based discount)
for Benefit Category 2 Riders. Similarly, for Benefit Category 1 Riders, the discount would be 3.75%.
Benefit Category 1 * - Accidental Death (AD) | Accidental Total & Permanent Disability (ATPD) | Accidental Disability Care (ADC)
Benefit Category 2 ** - Term Booster (TB) | CritiCare Plus (CCP) | Accelerated CritiCare (ACC) | Multistage CritiCare (MCC)
Cancer Care | Cardiac Care | HospiCare
Disclaimer
Vitality is a trademark licensed to Tata AIA Life by Amplify Health Assets PTE. Limited, a joint venture between Vitality Group International, INC. and AIA Company Limited.
The assessment under the wellness program shall not be considered as a medical advice or a substitute to a consultation/treatment by a professional medical practitioner.
Insurance cover is available under the Tata AIA products and are underwritten by Tata AIA Life Insurance Company Limited.
Tata AIA Life Insurance Company Limited ( IRDAI Regn. No.110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business
Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance
Company Ltd under a license. For any information including cancellation, claims and complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life’s nearest
branch office or call 1-860-266-9966 (local charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.
BEWARE OF SPURIOUS PHONE CALLS IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving
AND FICTITIOUS / FRAUDULENT OFFERS such phone calls are requested to lodge a police complaint

How To Register? Click to Download
1. 2. 3.
Fill in all the details as

Download the TATA AIA Vitality Click On Register
seen in snapshot below for
app from Playstore / Appstore
successful registration
YYYY/MM/DD C
A Enter the email ID that was used while D Enter insurer code recieved in the welcome
purchasing the linked insurance policy email and SMS fromTata AIA Life Insurance
(service@servicing.tataaia.com)
B Read Password instructions and create E Click on Register
your own password - For Example - Vitality1234
C Enter your Date of Birth in YYYY/MM/DD format
Disclaimer

How to Link & Sync Your Fitness Device/App with Vitality
1. 2. 3.
Wellness Devices and Apps
Get Linking
You don’t have any devices or apps linked yet. Choose
what you want to link from the list below and start
earning points for your daily habits.
Available to Link
GoogleFit
Samsung
Fitbit
Garmin
Polar
Suunto
Withings
Learn More
Help
Click on the Weekly Challenge *Click on “Link Now” to Select the device you want
banner on the home screen to successfully link to the app to link from the available list
activate your Weekly Challenges of devices/apps
4. 5.
Garmin Garmin
Earn points for your healthy habits, which contribute to

your Vitalife status and Weekly Challenge target.
Last Synced
LINK NOW
*Click on “Link Now” to SYNC NOW
successfully link to the app

Not Yet Synced
STEPS TO LINK
DELINK
Points Earning Metrics Points Earning Metrics
These metrics are used to track your healthy habits to These metrics are used to track your healthy
earn you points. habits to earn you points.
Your device or app may be capable of tracking some Your device or app may be capable of tracking some
or all of these metrics. Please ensure you verify its or all of these metrics. Please ensure you verify its
capabilities. Learn more... capabilities. Learn more...
**For sync, follow the same
process and Sync Now
Physical Activity Physical Activity
Heart Rate Heart Rate
Steps Steps
About Garmin Device About Garmin Device
Disclaimer
*Linking process screens are dependent on the device manufacturer. For Garmin, the device linking process is shown here. Actual screens may differ depending upon the device you want to link
**Sync happens automatically. However, it is recommended to “Sync Now” to ensure points that are seen on source app, are reflecting on Vitality app

CUSTOMER INFORMATION SHEET
Description is illustrative and not exhaustive
(UIN: 110A048V02) (A Non-Linked, Non- Participating Individual Health Rider)

1 Product Name
Benefit Option: Accidental Total & Permanent Disability
100% of the Insured Amount under this Benefit Option will be payable in the event of the Total and Permanent
Disability of the Life Insured due to an accident within the Benefit Option Term, provided the disability occurs within 180
days from that accident.
The benefit payable will be doubled if the Disability due to accident occurs under any of the circumstances specified in
Part C Clause 3.1 (III). Part C
What am I
2 Clause 3.1
covered for: The Life Insured can also avail additional services with this rider. Please refer Part C Clause 3.1 for details and 3.3
Tata AIA Vitality (if opted): Tata AIA Vitality is a science based comprehensive and personalized Wellness Program. It
rewards you with benefits at the time of opting for the rider with Wellness Program and subsequently throughout the
rider term. The rewards may be in the form of Discount on Premium, Premium Cashback, Cover Booster or Annual
Health Cashback.
Once you enroll for this program, in order to earn wellness benefits, you need to download and register on the 'Tata AIA
Vitality' app, as benefits would be basis Wellness Status achieved which shall be tracked through this app.
Accidental Disability Benefit shall be not payable for any losses caused directly or indirectly, wholly or partly, by any one
of the following occurrences:
● Disablement as a result of any disease or infection.
● Disablement arising due to any condition other than disablement solely and directly as a result of an accident.
● Any pre-existing condition or disability arising out of a pre-existing diseases or any complication arising therefrom.
Wherever the proximate cause is accident which has occurred after the rider inception date, this exclusion shall
not apply.
● If the Disability has not persisted for at least 180 days and is not in the opinion of a medical practitioner, deemed
to be permanent.
● Attempted suicide, attempted self-destruction or self-inflicted injury, irrespective of mental condition.
● Disablement arising from or caused due to use, abuse or a consequence or influence of an abuse of any substance,
intoxicant, drug, alcohol or hallucinogen
● Disablement arising out of or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations
What are the (whether war be declared or not or while performing duties in the armed forces of any country during war or at
peace time), participation in any naval, military or air-force operation, civil war, public defense, rebellion, Annexure 1
major
3 revolution, insurrection, military or usurped power ‘Exclusions’
exclusions in
the policy: ● Disablement caused by Participation by the insured person in any flying activity, except as a bona fide, fare-paying Section
passenger of a recognized airline on regular routes and on a scheduled timetable.
● Insured Person whilst engaging in a speed contest or racing of any kind (other than on foot), bungee jumping,
parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating
the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo,
snow and ice sports in so far as they involve the training for or participation in competitions or professional sports,
or involving a naval, military or air force operation and is specifically specified in the Policy Schedule
● Working in underground mines, tunnelling or explosives, or involving electrical installation with high tension
supply, or as jockeys or circus personnel, or engaged in Hazardous Activities
● Disablement arising or resulting from the Insured Person committing any breach of law or participating in an actual
or attempted felony, riot, crime, misdemeanor, or civil commotion with criminal intent.
● Disablement arising from or caused by ionizing radiation or contamination by radioactivity from any nuclear fuel
(explosive or hazardous form) or resulting from or from any other cause or event contributing concurrently or in
any other sequence to the loss, claim or expense from any nuclear waste from the combustion of nuclear fuel,
nuclear, chemical or biological attack.
Waiting
4 Not Applicable
Period
Fixed amount as described in Part C Clause 1 (III) of the Policy Document will be paid on the occurrence of a covered
event. You can choose to receive the benefits as a
1. Combination of Lump sum and income for a fixed income period chosen Part C
5 Payment Basis
2. Income till survival of chosen dependent partner(s) (Partner Care) Clause 3.5
3. Waiver of future premiums
For more details please refer Part C, Clause 3.5 of Policy Document.
6 Loss Sharing Not Applicable -
Renewal
7 Not Applicable -
Conditions
Renewal
8 Not Applicable -
Benefits
This policy will be cancelled, and no claim or refund would be due to you if
a) You have not correctly disclosed details about current and past health status OR Part F
b) Have otherwise encouraged or participated in any fraudulent claim under the policy OR Clause 6.4
9 Cancellation
c) In case of misrepresentation of material information and Part D
Clause 4.8
Also, this Benefit Option shall automatically terminate on the occurrence any of the events described in Part D Clause
4.8 of the Policy Document.

For processing the claim request under this rider, please share documents as listed under Part F Clause 6.2 of the Policy
Document. Part F
10 Claims
The evidence of travel in public land transportation, airline or visit to theatre, cinema, public auditorium, hotel will be Clause 6.2
required for Double Benefit claim to be considered.
Policy
Servicing/ Part D and
11 For details on policy servicing/grievances/complaints, please refer the terms and conditions of the base plan
Grievance/ Part G
Complaints
Insured’s ● Free look & Revival: For the purpose of this Supplementary Contract, the provisions of the base plan in respect of
12 Part D
Right Free look cancellation and revival, shall apply.
● Please disclose all pre-existing disease/s or condition/s before buying a Policy. Non-disclosure may result in claim
not being paid.
● Disclosure of Material Information and any changes therein during the Policy period should be communicated to
Insured’s us by Part F
13
Obligations o Sending an email to customercare@tataaia.com from your email id registered with us Clause 6.4
o Submission of the Request for Change form* (filled and signed) at any Tata AIA Life Insurance Branch or
Service Centre
*Request for Change form is available on our website – www.tataaia.com
1) Kindly note that this document does not substitute the Policy Contract.
2) In case the age is found to be higher/lower than the actual age, the rights and remedies would get affected
(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the Product Brochure and Policy Document. In case of any conflict between the
Customer Information Sheet and the Policy Document, the terms and conditions mentioned in the Policy Document shall prevail.
Tata AIA Life Insurance Company Limited (IRDAI Regn. No. 110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park,
Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance Company Ltd under a license.
For any information including cancellation, claims and complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life’s nearest branch office or call 1-860-266-9966 (local
charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.

CUSTOMER INFORMATION SHEET
Description is illustrative and not exhaustive
Product (UIN: 110A048V02) (A Non-Linked, Non- Participating Individual Health Rider)

1
Name Benefit Option: Accidental Death
Benefit Option: Accidental Death (AD):
The Insured Amount under this Benefit Option will be payable in the event of the death of the Life Insured due to an
accident within the Benefit Option Term, provided the death occurs within 180 days from the accident.
The benefit payable will be doubled if the death due to an accident occurs under any of the circumstances specified in
Part C Clause 3.1.
What am I Part C Clause
2
covered for: The Life Insured can also avail additional services with this rider. Please refer Part C Clause 3.1 for details 3.1 and 3.3
Tata AIA Vitality (if opted): Tata AIA Vitality is a science based comprehensive and personalized Wellness Program. It
rewards you with benefits at the time of opting for the rider with Wellness Program and subsequently throughout the
rider term. The rewards may be in the form of Discount on Premium, Premium Cashback, Cover Booster or Annual
Health Cashback.
Once you enroll for this program, in order to earn wellness benefits, you need to download and register on the 'Tata
AIA Vitality' app, as benefits would be basis Wellness Status achieved which shall be tracked through this app.
Accidental Death Benefit shall not be payable for any losses caused directly or indirectly, wholly or partly, by any one of
the following occurrences:
● Death as a result of any disease or infection
● Death arising due to any condition other than death solely and directly as a result of an accident
● Any pre-existing condition of disability arising out of Pre-existing diseases or any complication arising therefrom.
Wherever the proximate cause is accident which has occurred after the rider inception date, this exclusion shall
not apply.
● Suicide, attempted suicide, attempted self-destruction or self-inflicted injury, irrespective of mental condition.
● Death arising from or caused due to use, abuse or a consequence or influence of any abuse of any substance,
intoxicant, drug, alcohol or hallucinogen
● Death arising out of or attributable to foreign invasion, act of foreign enemies, hostilities, war like operations
(whether war is declared or not or while performing duties in the armed forces of any country during war or at
peace time), participation in any naval, military or air force operation, civil war, public defense, rebellion,
revolution, insurrection, military or usurped power.
What are the ● Death caused by Participation by the insured person in any flying activity, except as a bona fide, fare-paying Annexure 1
major passenger of a recognized airline on regular routes and on a scheduled timetable.
3 ‘Exclusions’
exclusions in ● Insured Person whilst engaging in a speed contest or racing of any kind (other than on foot), bungee jumping,
the policy: Section
parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating
the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus,
polo, snow and ice sports in so far as they involve the training for or participation in competitions or professional
sports, or involving a naval, military or air force operation and is specifically specified in the Policy Schedule.
● Working in underground mines, tunnelling or explosives, or involving electrical installation with high tension
supply, or as jockeys or circus personnel, or engaged in Hazardous Activities.
● Death arising or resulting from the Insured Person committing any breach of law or participating in an actual or
attempted felony, riot, crime, misdemeanor, or civil commotion with criminal intent.
● Death arising from or caused by ionizing radiation or contamination by radioactivity from any nuclear fuel
(explosive or hazardous form) or resulting from or from any other cause or event contributing concurrently or in
any other sequence to the loss, claim or expense from any nuclear waste from the combustion of nuclear fuel,
nuclear, chemical or biological attack.
No benefits will be payable for any condition(s) which is a direct or indirect result of any pre-existing conditions unless
Life Insured has disclosed the same at the time of proposal or date of revival whichever is later and the Company has
accepted the same.
Waiting
4 Not Applicable
Period
Fixed amount as described in Part C Clause 1 (II) of the Policy Document will be paid on the occurrence of a covered
event. You can choose to receive the benefits as a
Payment Part C
5 1. Combination of Lump sum and income for a fixed income period chosen
Basis Clause 3.5
2. Income till survival of chosen dependent partner(s) (Partner Care)
For more details please refer Part C, Clause 3.5 of Policy Document.
6 Loss Sharing Not Applicable -
Renewal
7 Not Applicable -
Conditions
Renewal
8 Not Applicable -
Benefits:
This policy will be cancelled, and no claim or refund would be due to you if
a) You have not correctly disclosed details about current and past health status OR Part F
b) Have otherwise encouraged or participated in any fraudulent claim under the policy OR Clause 6.4 &
9 Cancellation
c) In case of misrepresentation of material information Part D
Clause 4.8
Also, this Benefit Option shall automatically terminate on the occurrence any of the events described in Part D Clause
4.8 of the Policy Document

For processing the claim request under this rider, please share documents as listed under Part F Clause 6.2 of the Policy
Document. Part F
10 Claims
The evidence of travel in public land transportation, airline or visit to theatre, cinema, public auditorium, hotel will be Clause 6.2
required for Double Benefit claim to be considered.
Policy
Servicing/ Part D and
11 For details on policy servicing/grievances/complaints, please refer the terms and conditions of the base plan
Grievance/ Part G
Complaints
Insured’s ● Free look & Revival: For the purpose of this Supplementary Contract, the provisions of the base plan in respect of
12 Part D
Right Free look cancellation and revival, shall apply.
● Please disclose all pre-existing disease/s or condition/s before buying a Policy. Non-disclosure may result in claim
not being paid.
● Disclosure of Material Information and any changes therein during the Policy period should be communicated to
Insured’s us by Part F
13
Obligations o Sending an email to customercare@tataaia.com from your email id registered with us Clause 6.4
o Submission of the Request for Change form* (filled and signed) at any Tata AIA Life Insurance Branch or
Service Centre
*Request for Change form is available on our website – www.tataaia.com
1) Kindly note that this document does not substitute the Policy Contract.
2) In case the age is found to be higher/lower than the actual age, the rights and remedies would get affected
(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the Product Brochure and Policy Document. In case of any conflict between the
Customer Information Sheet and the Policy Document, the terms and conditions mentioned in the Policy Document shall prevail.
Tata AIA Life Insurance Company Limited (IRDAI Regn. No. 110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park,
Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance Company Ltd under a license.
For any information including cancellation, claims and complaints, please contact our Insurance Advisor / Intermediary or vis it Tata AIA Life’s nearest branch office or call 1-860-266-9966 (local

SERVICE OPTIONS
Log in to one stop shop for your servicing needs
My
DigiAccount
How to login?
Visit https://myinsurance.tataaia.com
Authenticate your policy details and date of birth
Verify your registration via OTP
Your registration is now complete
Features
Simplifed OTP-based login Buy products online
single dashboard with

key policy information Easy servicing options
Pay premium, download Read interesting

receipts & statements blogs & articles
Set notification on
policy milestones
Where to pay premium
Pay on Website
Bank Website
https://apps.tataaia.com/PG/#!/policyPayment
Apps (PayZapp, Paytm, Google Pay,

My DigiAccount
Phone Pe, Jio Money, Airtel Money,
https://myinsurance.tataaia.com Itz Cash, MobiKwik, Amazon Pay)

How to pay premium?
Credit card/debit card
Netbanking
Mobile wallets
Bharat Bill Payment System (BBPS)
UPI
Watch our video on premium payment options
https://youtu.be/Dg1CYdlBa8w
Hassle-free Standing Instructions

Ensure Non-Stop Rakshakaran by registering for Standing Instructions where premium amount
will automatically get debited on due date.
Register on https://apps.tataaia.com/PG/#!/RegAutoDebt using Credit Card or Bank Account
Ways to access digital policy document
SMS Email WhatsApp My DigiAccount DigiLocker e-Insurance

Account

Claims Process
Claim with ease
Step 1 Register claim with necessary documentation
Step 2 Documents are verified and claim is processed
Step 3 Claim amount is disbursed
Options to inform us
claims@tataaia.com
Type CLAIM & send to +91 7045669966
Visit our website

https://www.tataaia.com/customer-service/claim-registration.html
Locate your nearest branch from

https://www.tataaia.com/contact-us.html?contactUs-2
Write to us at Tata AIA Life Insurance Company Limited, Claims department, 9th Floor,
B wing, I-Think Techno Campus (Lodha), Behind TCS, Pokhran Road No.2, Thane
(West), Mumbai – 400607
Watch our claim settlement process on https://youtu.be/BaIjmQ5X6k0

Connect with us for any query/request
customercare@tataaia.com www.tataaia.com
Send Hi to +91 7045669966
1-860-266-9966 (Mon - Sat | 10 am - 7 pm IST),

022-6251 9966 (Outside India)
SMS PCT <space> Policy no.<space>

Registered Email ID to 5676799
Locate your nearest branch from

https://www.tataaia.com/contact-us.html?contactUs-2
Frequently Asked Questions
• Login to My DigiAccount from

https://myinsurance.tataaia.com
How to update personal details? • You can update name, email ID, mobile number,
NEFT details, PAN, address,
Standing Instructions details here.
• Digital document is equivalent to physical document. If

I need my physical policy document.
you still need it, you can send an email to
How can I get it?
customercare@tataaia.com requesting for a copy.
customercare@tataaia.com
• Login to My DigiAccount from

Need to update nominee/beneficiary? https://myinsurance.tataaia.com
• Visit any Tata AIA Life Insurance branch
• Send a request by logging to My DigiAccount from

Need to change your
payment frequency? https://myinsurance.tataaia.com
• Visit any Tata AIA Life Insurance branch
Need to know about Freelook Charges? Refer to Freelook Cancellation Clause of the T&C, in case you
exercise freelook option to cancel the policy, you shall
receive all premiums paid without interest after the
deduction of proportionate risk premium for the period of
cover, stamp duty as mentioned on the preamble page of the
policy document, medical examination costs and taxes as
applicable. Kindly note that if you have chosen monthly mode
of premium payment, the total deductible charges may be
higher than the amount of modal premium paid by you.

Tata AIA Life Insurance Company Limited.
PROPOSAL FORM
Unit Linked Products
Kindly Fill the form in CAPITAL and only in blue or black

(For Official Use only)
Proposal Number: U242922179 Branch Code: MU01
Channel: Broking Campaign Code:
Sub Office Code: RM CAMS Code: 4967389
POS/Agent/Broker/Specified Person/Employee: Policy Bazaar

Code: Contact Details: License No. & Validity Details:
Customer Relationship No. (For Bancassurance Channel) PAN No.
IMPORTANT GUIDELINES: 1) IN UNIT-LINKED INSURANCE POLICIES (ULIPs), THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE
POLICYHOLDER. 2) Insurance is a contract of utmost good faith between the Insurer and the Insured. The Proposer and the Life to be Assured are required to disclose all
facts in response to the questions in this application form. 3) Any cancellation/alteration is to be signed by Proposer/Life to be assured as applicable. 4) KYC documents
will be required for all the parties to the contract.
I. GENERIC DETAILS Please [ ] your answer

Is this policy self-proposed? Yes . If No, please answer the following details Type of Proposer: Individual
Relation with Life Assured: Self Type of Proposal:
II. ELECTRONIC INSURANCE ACCOUNT (eIA) DETAILS OF THE PROPOSER/POLICYOWNER
e-Insurance Account Number (eIA), if any,
I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Tata AIA Life Insurance Company Ltd. In electronic
format(Physical copy would be sent even if proposer opts for electronic format; however, in case proposer has e-Insurance Account, only electronic copy of the Insurance
Policy will be provided)
I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Insurance Repository in the Electronic Format as and
when applicable. Please select the name of the Insurance Repository.
NSDL Data Management Limited
III. PRODUCT DETAILS
Sum Assured Policy Premium Premium ( ) (Inclusive of applicable Premium Paying

Base Plan Name
( ) Term (Years) Paying Term(Years) taxes, cesses & levies ) Mode

15000000 40 5 8500 Monthly
Sampoorna Raksha
Tata AIA Vitality Protect Plus (Accidental Total
5000000 40 5 1198 Monthly
and Permanent Disability)
Tata AIA Vitality Protect Plus (Accidental Death) 5000000 40 5 1643 Monthly
Premium Benefit Payout Option Details Premium ( )

Life
Rider (Benefit Term Paying Return of Premium (inclusive of
Insured Lumpsum ( Income Income Income
Option) Name (Years) Term Option applicable taxes,
Name ) p.a ( ) Duration(Years) Frequency
(Years) cesses & levies)
Tata AIA Vitality
Protect Plus Gautam
40 5 Lumpsum 5000000 NA NA NA
(Accidental Total and Pratyush
Permanent Disability)
Tata AIA Vitality
Gautam
Protect Plus 40 5 Lumpsum 5000000 NA NA NA
Pratyush
(Accidental Death)
Tata AIA Vitality (Wellness Program Applicable only for specific product/riders): Yes
Utilization of Rewards during the Premium Payment Term (if ‘Vitality Wellness Program’ is opted):Premium Discount
FUND SELECTION DETAILS a. Kindly mention the names of the fund chosen b. Incase you opt for a specific Portfolio Strategy (as available with individual products), kindly mention the Fund Names or
other details as applicable c. Kindly fill in whole numbers in percentage only. Decimals and Fractions not allowed.
Name of Fund % Allocation Portfolio Strategy

Whole Life Mid Cap
20
Equity Fund Funds for the chosen Portfolio Strategy (If Applicable )
OR
Multi Cap Fund 30 Debt oriented fund Equity oriented fund
India Consumption Fund 30
Top 200 fund 20 Other Details(if applicable)
IV. PROPOSER / POLICYHOLDER DETAILS (Please fill in details of Life Assured if same as Proposer)
1. Title Mr
2. Name Gautam Pratyush
3. Father's Name / Spouse Name SANJAY KUMAR
4. Mother's Name VINITA KUMARI
5. Maiden Name(For female lives only)

6. Gender/Date of Birth MALE/ 15-10-1999

7. Which is your Dominant Hand? (Question to be answered only if ADDL Rider is
Right
selected )
8. Marital Status Single

Nationality: Resident Indian
Country of Residence : India
9. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
(If country of residence or nationality outside India then FATCA/ CRS-Self Certification
Form to be mandatorily completed)
Residence for Tax purposes in Jurisdiction(s) outside India No (If 'Yes' then FATCA/ CRS-Self Certification Form to be mandatorily completed)
10. Highest Educational Qualification Graduate
S/O SANJAY KUMAR NAYA TOLA, KUMHARAR, CHANAKY A NAGAR NEAR ASHOK
KUMAR SINGH HOUSE
11. Correspondence Address Landmark: BEHIND LALITA RAJ
City: PATNA
APPARTMENT
State: BIHAR Country: India Pin code: 800026
S/O SANJAY KUMAR NAYA TOLA, KUMHARAR, CHANAKY A NAGAR NEAR ASHOK
KUMAR SINGH HOUSE
12. Permanent/Updated Address
Landmark: BIHAR City: PATNA
State: BIHAR Country: India Pin code: 800026
13. Address for Communication Correspondence Address
Residence No: +91 Mobile No: 9199878315
14. Telephone and Email Details
E-mail: gpsk3099@gmail.com
15. Occupation Class Self Employed
a. Name of Organisation /School / College BAGIT KART
b. Organisation Type Proprietorship Firm
c. Industry Information Technology
d. Nature of Work Sales and Marketing
e. Annual Income ( ) 700000
16. Income Proof Salary certificate of current financial year
17. Identity Proof (In case of Passport & Driving License please mention expiry date) Aadhar Card, Uid
18. Address Proof (Utility bills should not be older than 2 months) Aadhar Card, Uid
EFXPP1591H (kindly attach copy of Pan card)
19. Permanent Account Number ( PAN ) :
Yes I do have PAN (kindly attach copy of Form 60 duly signed)
20. CKYC No. (If available) 60003169975648
21. Source of Funds
22. Are you a Politically Exposed Person? No (Definition of PEP: "PEP are individuals who are or have been entrusted with prominent public functions, domestically/in an international
organisation /in a foreign country. This would include individuals who have or have had positions of Heads of State or of government, senior politicians, senior government, judicial or military officials, senior
executives of state owned corporations, important political party officials". "Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity)
or through marriage or similar (civil) forms of partnership. Close associates are individuals closely connected to a PEP, either socially or professionally")
IV. LIFE ASSURED DETAILS (Please fill in this section only if Life Assured is different from Proposer)
1. Title
2. Name
3. Maiden Name(For female lives only)
4. Gender/Date of Birth
5. Which is your Dominant Hand?
Question to be answered only if ADDL Rider is
selected)
6. Marital Status
7. Life Stage
8. Nationality (If other than resident Indian, Passport as

an age proof is mandatory) Country of Residence

8. Highest Educational Qualification
9. Occupation Class
10. Name of Organisation/ School/College
11. Organisation Type
12. Industry
13. Nature of Work
14. Annual Income ( )
15. Income Proof
Expiry Date :
16. Identity Proof (In case of Passport & Driving License please mention expiry date)
Others :
17. Address Proof for updated address
(kindly attach copy of Pan card)
18. Permanent Account Number (PAN):
I Do not have PAN (kindly attach copy of Form 60 duly signed)
19. Are you a Politically Exposed Person? (Definition of PEP: "PEP are individuals who are or have been entrusted with prominent public functions, domestically/in an international organisation /in a
foreign country. This would include individuals who have or have had positions of Heads of State or of government, senior politicians, senior government, judicial or military officials, senior executives of
state owned corporations, important political party officials". "Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar
(civil) forms of partnership. Close associates are individuals closely connected to a PEP, either socially or professionally")
VI. HEALTH & LIFESTYLE DETAILS OF THE LIFE ASSURED

1. Nature of Age proof (Non-standard age proof submission will attract extra premium)
Aadhar Id Card - Standard
2. a) Height (cms or ft) 172.72cms b) Weight ( kg or lbs). 90Kg
PART A: LIFESTYLE DETAILS

1. Are you employed in the Armed Forces, Paramilitary, Police Forces, Fire Brigade or any other similar occupation? No
2. Is your occupation/your hobbies associated with any specific accident/health hazard or are dangerous in any way (e.g. working with dangerous or
corrosive chemicals, explosives, radiation, working underwater/underground or at height, working in mines, non-commercial flying activities, diving, No
mountaineering, any form of motorbike/car racing etc.)?
3. Do you intend to live or travel outside India for more than 30 days for reason other than family vacation in next 6 months? No
4. Have you ever been charge sheeted or convicted of any criminal proceedings or have any criminal case or charge pending against you in any
No
court of law in India or abroad? If Yes, please provide complete details.
5. Do you consume or have consumed any of the following? Please tick all relevant options and provide details
Substance Quantity/ Per Day for Tobacco & Per No. of If stopped consumption, mention month and year in
Yes/ No Consumed As
Consumed week for Alcohol and Narcotics Years which last consumed
Tobacco No
Alcohol No
Any Narcotics No
PART B: HEALTH & PERSONAL DETAILS
1. Has any of your insurance application or reinstatement application on life, accident, medical or health, critical illness, or disability ever been
No
declined, postponed or accepted at extra premium or modified terms?
2. Did you have any loss or Gain of weight of 10 kgs or more in the last six months? No
3. Do you have any physical deformity / handicap or congenital defect / abnormality? No
4. Have you ever been advised to and / or have undergone any tests, investigations or surgery or had signs or symptoms of any condition, aliment
No
or injury and / or were advised treatment for or have been hospitalized for check-up or treatment other than minor flu, cold or influenza?
5. Have you ever been diagnosed with or investigated for any of the following:
a. Cardio: High or Low Blood Pressure / Raised Cholesterol / Chest Pain / Palpitation / Rheumatic Fever / Heart Murmur / Shortness of Breath /
No
Heart Attack / Stroke / Any other heart condition
b. Hormonal: High Blood Sugar/ Diabetes / Thyroid or endocrine disorder / Sugar in Urine / Any other hormonal disorder No
c. Respiratory: Asthma / Tuberculosis / chronic cough, chronic bronchitis, emphysema, pneumonia / Any other respiratory disorder No
d. Blood/Cellular: Cancer / Tumor or malignant growth / Leukemia / Anemia / Enlarged lymph nodes/ Any blood disorder No
e. Digestive/Regulatory: Recurrent indigestion / Gastritis / Stomach or Duodenal Ulcer / Hernia / Jaundice / Disorders of the liver / Cirrhosis and
No
Gastrointestinal System/ Any other disease

f. Mental/Psychiatric / Neurological ailment: Symptoms or ailment relating to Brain Depression / Anxiety / Brain Disorder or disease / Mental /
Psychiatric / Transient ischemic attack /Parkinson's disease / Multiple Sclerosis / Nervous disorder / Paralysis or Paraplegia / Epilepsy / Any other No
mental or psychiatric ailment
g. Neural/Skeletal/Muscular: Musculoskeletal disorders such as Arthritis / Recurrent Back Pain / muscular dystrophies/ musculoskeletal
deformities/ Slipped disc or any other disorder of Spine, Joints, Limbs or Leprosy; / Disorders of Eye, Ear, Nose,Throat including defective sight / No
Disorder of speech or hearing and discharge from ears / Any other disorder
h. Infectious/Contagious: Were you or your spouse ever tested for Hepatitis B or C, HIV /AIDS or any other Sexually Transmitted Disease / Any
No
other disorder
i. Genitourinary: Hydrocele / fistula / piles / symptoms or ailment relating to Kidney / Kidney Stones/ Prostate, Urinary System or Reproductive
No
System / Any other disorder
6. Have you had/ are having any other illness or impairment not mentioned above? No
7. Are you presently in good health? Yes
8. Has any of your family member (Parents and Siblings) ever been diagnosed with diabetes, Hypertension, Kidney Failure, Cancer, Heart Attack or
Yes
any Hereditary Disorder before the age of 60?
9. Have you ever been advised to undergo any surgery or treatment or laboratory investigations (stress ECG, echocardiogram, angiography,
No
MRI/CT scan etc.) by any doctor or specialist?
10. Have you been off work due to illness for a continuous period of 7 days and above during the last 5 years? No
11. Female Life Questionnaire
a. Are you now Pregnant? If Yes, kindly state expected delivery date
b. Have you undergone any gynecological investigations for illness, internal checkups, breast checks such as mammogram or biopsy?
c. Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, fallopian tubes, menstruation, complications
during pregnancy or child delivery or a sexually transmitted disease?
d. Have you suffered from any other disorder of the breast or reproductive organs, abnormal smear test(s) and irregular menses?
12. If answer to any of the question above is 'yes', kindly give full details noting the question number (attach relevant copies)
Question No.: Details:
8.
13. Family Details (Mandatory if the life to insured is Juvenile/Student/Housewife)
Gender(Male/Female/ Date of
Family Details Name Occupation Annual Income ( ) Insurance Details (Existing /Applied for)
Transgender) Birth
Father/Husband
First Child / Sibling
Second Child / Sibling
14. Family Details to be filled for Life Assured only Father Mother Brother Sister Spouse
a. If Alive, Health Status Good
b. If Deceased, Cause of Death Stroke
c. Age at Death/Current Age 54 46
VII. EXISTING INSURANCE DETAILS
Do you currently hold or have applied for Life Insurance/Pension/Health (Cancer/Cardiac/Critical Illness) /Personal Accident Policies? Y / N If Yes, kindly
provide details as below:
Life Assured Proposer (If Life Assured is Juvenile/Student/Housewife)
Type of Insurance (Life/ Health Type of Insurance (Life/ Health
Company Basic Sum Company Basic Sum
(Cancer/Cardiac/Critical Illness)/ Unit Linked (Cancer/Cardiac/Critical Illness)/ Unit Linked
Name Assured ( ) Name Assured ( )
/Pension/Personal Accident) /Pension/Personal Accident)
Star Union
Unit Linked Rs. 600,000/-
Dai-ichi
VIII. NOMINEE DETAILS (Required only if Proposer & Life Assured are the same)
PARTNER DETAILS (only if ‘Partner Care’ payout option has been opted )
Gender
Base Plan/ Rider Percentage ( % ) (Do not enter % in decimals & total % should be
Name Date of Birth (Male/Female/ Relationship
(Benefit Option)Name equal to 100)
Transgender)
VINITA
Smart Sampoorna 05-08-1977 Female Mother 100
KUMARI
Raksha
IX. APPOINTEE DETAILS (Required only if Nominee is less than 18 years of age)
Gender (Male/Female/
Name Date of Birth Relationship
Transgender)

X. PAYMENT DETAILS
Premium Payment Method: Digital/Online Payment
Name of Credit Card/Debit Card Holder: Credit Card/Debit Card Number
Cheque/DD No. Issuing Bank Branch Amount Rs. 11341 Date: DD/MM/YYYY
Premium# 10907 + Taxes, cesses & levies 434 = Total Payment 11341 for months initial deposit (To be filled for monthly mode only)
On the first policy/modal anniversary I would like to change the premium payment mode to , subject to policy contract provisions. For Annual/Monthly mode issued #
policies mode change shall be accepted only on completion of first policy anniversary. #Premium is exclusive of applicable taxes, cesses & levies. All Premiums are
subject to applicable taxes, cesses & levies which will entirely be borne by the Policyholder and will always be paid by the Policyholder along with the payment of
Premium. If any imposition (tax or otherwise) is levied by any statutory or administrative body under the Policy, Tata AIA Life Insurance Company Limited reserves the
right to claim the same from the Policyholder. Alternatively, Tata AIA Life Insurance Company Limited has the right to deduct the amount from the benefits payable by Us
under the Policy. Cheque/DD should be drawn in favor of "Tata AIA Life Insurance Company Ltd. (Proposal No)". Do not issue blank cheque.
Renewal Payment Mode:
XI. Mandatory Bank Account Details:

Please provide below bank details. Bank details provided should be in the name of Proposer. All policy payouts will be made to the below mentioned bank account through
electronic transfer (NEFT). Payout would be in accordance and subject to terms and conditions of the policy.
Name of Account
Bank Account No. Bank Name and Branch Account Type IFSC Code
Holder
ICICI BANK LIMITED,H 39 DOCTORS COLONY KANKERBAGH
Gautam Pratyush 030701516771 Savings ICIC0000307
PATNA 20 800020
Note: 1. Please provide a cancelled copy of your personalized cheque. If personalized cancelled cheque is not available, attach bank statement showing account holder
name, address and account number. 2. In case of Non-Credit to the given bank account with/without assigning any reason thereof or if the transaction is delayed or not
effected at all for any reason of incomplete information, Tata AIA Life Insurance Co Ltd will not be responsible. 3. Further, the Company reserves the right to use any
alternative payout option inspite of opting for Direct Credit option. 4. If Account type is NRE/NRO then FATCA/CRS-Self Certification Form to be mandatorily completed.
XII. DECLARATION & CONSENT

• I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all respects to the
best of my knowledge and that I am authorised to propose on behalf of these other persons (applicable where the proposer and life insured are different).
• I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy will come into
force only after full payment of the premium chargeable.
• I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before
communication of the risk acceptance by the company.
• I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/ proposer or from any past or
present employer concerning anything which affects the physical or mental health of the person to be insured/ proposer and seeking information from any insurer to whom an application for
insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
• I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer (if any) for the sole purpose of underwriting the proposal and/or claims
settlement and with any Governmental and/or Regulatory authority.
• I confirm that I have understood the contents of this Proposal Form and I am submitting this Proposal Form with all the details which are true and correct. I have not withheld any material
information or suppressed any fact which are essential for issuance of the policy. I also hereby irrevocably authorize the Company to ascertain all the details from any third parties, as may be
required for assessing the risk.
• I agree to undergo all medical tests as determined by the Company for obtaining the policy and I further understand that the Company reserves the right to issue the policy if all the required criteria
are met and in case of any fraud or misrepresentation being established, the insurer shall take action in accordance with Section 45 of the Insurance Act, 1938 as amended time to time. I
understand that the contract will be governed by the provisions of the Insurance Act, 1938 as amended time to time, the IRDA Act, 1999 and the Regulations framed there under and that the
contract will not commence until the Company's written acceptance of this Proposal Form is received. In case of the life to be insured being a minor, I further declare and affirm that this proposal of
insurance is for the benefit of the life to be insured.
• Anti-Money Laundering Declaration: I hereby confirm that all premiums will be paid from bonafide sources and no premiums will be paid out of proceeds of crime related to any of the offence
listed in Prevention of Money Laundering Act, 2002. The Company has the right to peruse my financial profile and also agree that the Company has right to cancel the insurance contract in case I
have been found guilty of any of the provisions of any law, directly or indirectly, having relation to the laws governing prevention of money laundering in the country, by any competent court of law.
• I/We understand that in accordance with the IRDAI (Protection of Policyholders Interests) Regulations, 2017, the insurer is permitted to share policyholder information only with the statutory
authorities. I permit/authorize the Company to collect, store, communicate and process information relating to the Policy/Account and all transactions therein, by the Company and any of its
affiliates or service providers wherever situated including sharing, transfer and disclosure between them or with any entity or entities for the purpose of underwriting, policyholder servicing and
claims; and to the authorities in and/or outside India for compliance with any law or regulation whether domestic or foreign.
Date: 14-11-2023
Signature/Thumb Impression of Life Assured Signature/Thumb impression of Proposer Place: PATNA
Authenticated through OTP Authenticated through OTP
I hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I undertake to inform you of any changes therein, immediately in case any of the above
information is found to be false or untrue or misrepresenting, before issuance of the proposal. "I, the undersigned confirm that I have verified photocopies of the proofs submitted along with this proposal
form against the originals and certify the same to be true copy".
I declare and confirm that I have carried out necessary suitability analysis while advising this product to the proposer and that the product is suitable to the proposer.
WHERE THE PROPOSAL FORM IS FILLED IN BY AGENT/INTERMEDAIRY/EMPLOYEE: I hereby declare that I have explained the contents of this proposal to the Proposer/Annuitants in the language
known to him/her and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer/ Annuitant’s responses to the information sought in the proposal form and I
have read out the responses to the Proposer/Annuitants and he/she has confirmed that they are correct
Signature of Agent/ Specified Person/ Broker/ Employee
________________________________________________________________________________________________________________________________________
ACKNOWLEDGEMENT
Tear away portion (To be handed over to the customer)
Proposal Number: ___________________
Dear Customer
We acknowledge receipt of your Cash/Cheque/DD for Rs.______________ by number ______________ dated ___ /___ /___ drawn on _______________ toward' s Initial Deposit. We request you to kindly
verify the details filled in the proposal form before signing the same. Please do insist on Official Receipt issued by Tata AIA Life from your advisor within 2 working days from submission of this proposal
form. In case you do not hear from us or do not receive your policy within 15 days from the date of submission of your proposal, please visit us at www.tataaia.com or call our helpline number 1860 266
9966 (local charges apply) or email us at customercare@tataaia.com.
This is only acknowledgement slip and not the premium receipt.
Agent code Agent name Signature of Agent Date of Acknowledgement

IN CASE OF THUMB IMPRESSION OF PROPOSER/ANNUITANTS OR WHERE THE ANSWERS/SIGNATURE OF THE PROPOSER/ANNUITANTS ARE IN
VERNACUL
Note: The below must be declared by someone other than advisor/employee of the company.
I, _______________________________________ (name) have explained the contents of this proposal to the _________________________________________
(Proposer) in ____________________ (language) and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer
responses to the information sought in the proposal form and I have read out the responses to the Proposer and he/she has confirmed that they are correct.
Date: 14-11-2023
Place: PATNA
(Signature of the person making the declaration)
Address of the person making the declaration:
Declaration by Proposer/Life Assured:

I have understood the contents of this proposal explained to me in language and confirm that the responses provided by me are correct.
Date: Date: 14-11-2023

Place: Place: PATNA
Signature/Thumb Impression of the Life Assured Signature/Thumb impression of Proposer
(Prohibition of Rebates) Section 41 - of the Insurance Act, 1938 as amended from time to time: 1. No person shall allow or offer to allow, either directly or indirectly,
as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or
part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate,
except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
SECTION 45 OF THE INSURANCE ACT, 1938 STATES: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years
from the date of policy, i.e. from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the
policy, whichever is later. A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of
commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that the insurer shall have
to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision is based.
Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question
merely because the terms of the policy adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal. For further details, please refer to
the Insurance Act, as amended from time to time.
Disclaimers: IN CASE OF A ULIP POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER. Tata AIA Life Insurance
Company Limited is only the name of the Company and any contract bearing the prefix "Tata AIA Life" is only the name of the contract and does not in any way indicate the
quality of the contracts, its future prospects or returns. Premium paid in ULIP is subject to investment risks associated with capital markets & the NAV of the units may go up
or down based on the performance of the funds and factors influencing capital markets and the insured is responsible for his decision. Past performance is not indicative of
future results. For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale.
BEWARE OF SPURIOUS PHONE CALLS IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public
AND FICTIOUS / FRAUDULENT OFFERS receiving such phone calls are requested to lodge a police complaint
Full Form for abbreviations used:

HUF – Hindu Undivided Family | MWPA – Married Women’s Property Act | OCI – Overseas Citizen of India | NRI – Non-Residential Indian
PIO – Person of Indian Origin | FATCA - Foreign Account Tax Compliance Act | CRS – Common Reporting Standard |CKYC – Central Know Your Customer
Area census code is an identifier of the location as rural / urban as per the latest census.
L&C/Misc/2023/Jul/0378/ULIP/V1
________________________________________________________________________________________________________________________________________
1. Please carry valid Identity card to the medical examination center wherever applicable. 2. For cash payment, please visit our nearest Tata AIA Life branch. Please do
not handover cash to Agent. If handed over to the agent, the company will not be liable for any loss. 3. In case there is any change in the particulars given above including
Life Assured/Proposer's health and/or medical and/or financial and/or occupational status and/or being charged with and/or arrested for any criminal offence after the date
of proposal but before risk acceptance by the company; please inform the company. 4. Acceptance of premium does not constitute risk commencement. 5. Risk
commencement starts after the acceptance of risk by the company. 6. Freelook Period: If you are not satisfied with the terms & conditions/features of the policy, you have
the right to cancel the Policy by providing written notice to the Company and receive the premiums after deducting a) Proportionate risk premium for theperiod on cover &
b) Stamp duty and medical examination costs including applicable taxes, cesses & levies, which have been incurred for issuing the Policy. Such notice must be signed by
you and received directly by the Company within 15 days from the date of receipt of the policy document by you or person authorized by you. The said period of 15 days
shall stand extended to 30 days, if the policy sourced through distance marketing mode which includes solicitation through any means of communication other than in
person. For Unit Linked Life Insurance products, you would receive the non - allocated premiums plus charges levied by cancellation of units plus fund value at the date of
cancellation and after deducting the charges as mentioned in (a) & (b) above.
Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110 CIN: U66010MH2000PLC128403). Registered & Corporate Office: 14th Floor, Tower A, Peninsula
Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA
Life Insurance Company Ltd under a license. For any information including cancellation, claims and complaints, please contact our Insurance Advisor/ Intermediary or visit
Tata AIA Life's nearest branch office or call 1- 860-266-9966 (local charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com

Congratulations on becoming your family's Param Rakshakarta !!
Today, protection is the need of the hour and we are privileged that you have chosen us as your Rakshakaran partner. We are delighted that you have opted for one of our comprehensive
solutions that will provide Life Cover as well as market-linked returns and protection for your health - helping you secure your loved ones' financial future. Param Rakshakaran also offers a
holistic wellness program - Tata AIA Vitality - which partners with you to help you focus on your physical and mental wellbeing while keeping you motivated with various discounts and benefits.
The comprehensive solutions will provide following benefits:
All in all, these solutions will cater to your protection, wealth and health protection needs. At Tata AIA Life Insurance, we are committed to help you with solutions that will provide Param
Rakshakaran to your family so that you can enjoy life without any worries.
Best Wishes

Param Rakshak solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha and Tata AIA Vitality Protect Plus
Param Rakshak Plus solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha, Tata AIA Vitality Protect Plus and Tata AIA Vitality Health Plus
Tata AIA Life Insurance Smart Sampoorna Raksha, A Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and Protection (UIN:110L156V02); Tata AIA Vitality Protect
Plus, Non-linked, Non-participating, Individual Health Rider (UIN: 110A048V02) and Tata AIA Vitality Health Plus, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A047V02).
*Tata AIA Vitality: A Wellness Program that offers you an upfront discount at policy inception. You can also earn premium discount / cover booster (as applicable) for subsequent years on policy
anniversary basis your Vitality Status (tracked on Vitality app)
Disclaimers: THE LINKED INSURANCE PRODUCT DO NOT OFFER ANY LIQUIDITY DURING THE FIRST FIVE YEARS OF THE CONTRACT. THE POLICY HOLDER WILL NOT BE ABLE TO
SURRENDER/WITHDRAW THE MONIES INVESTED IN LINKED INSURANCE PRODUCTS COMPLETELY OR PARTIALLY TILL THE END OF THE FIFTH YEAR. For more details please refer
to the customized benefit illustration and terms & conditions of the product. In case of any inconsistency between this letter and policy document, the policy document shall always prevail.
Vitality is a trademark licensed to Tata AIA Life by Amplify Health Assets PTE. Limited, a joint venture between Vitality Group International, INC. and AIA Company Limited. The assessment
under the wellness program shall not be considered as a medical advice or a substitute to a consultation/treatment by a professional medical practitioner. All investments made by the
Company are subject to market risks. The Company does not guarantee any assured returns. The Investment income and price may go down as well as up depending on several factors
influencing the market. Please know the associated risks and the applicable charges, from your Insurance Agent or the Intermediary or Policy Document issued by the Insurance Company.
Please make your own independent decision after consulting your financial or other professional advisor. The performance of the managed portfolios and funds is not guaranteed and the
value may increase or decrease in accordance with the future experience of the managed portfolios and funds. The solutions are underwritten by Tata AIA Life Insurance Company Limited.
The solutions are not guaranteed issuance solutions and it will be subject to Company's underwriting and acceptance. Buying a Life Insurance Policy is a long-term commitment. An early
termination of the policy usually involves high costs and the surrender value payable may be less than all the premium paid. Unit Linked Life Insurance products are different from traditional
insurance products and are subject to risk factors. The fund is managed by Tata AIA Life Insurance Company Ltd. (hereinafter the 'Company'). Tata AIA Life Insurance Company Limited is only
the name of the Insurance Company & Tata AIA Life Insurance Smart Sampoorna Raksha is only the name of the Unit Linked Life Insurance contract and does not in any way indicate the
quality of the contract, its future prospects or returns. Various funds offered under this contract are the names of the funds and do not in any way indicate the quality of these plans, their future
prospects and returns. Premium paid in Unit Linked Life Insurance policies are subject to investment risks associated with capital markets and the NAVs of the units may go up or down based on
the performance of fund and factors influencing the capital market and the insured is responsible for his/her decisions. Past performance is not indicative of future performance. Returns are
calculated on an absolute basis for a period of less than (or equal to) a year, with reinvestment of dividends (if any). Life insurance cover is available under the solution. For details on products,
associated risk factors, terms and conditions please read Sales Brochure carefully before concluding a sale. The precise terms and condition of this plan are specified in the Policy Contract.
L&C/Misc/2023/Oct/0509.
Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati
Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd & AIA Group Ltd. & is used by Tata AIA Life Insurance Company Ltd under a license. For
any information including cancellation, claims & complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life's nearest branch office or call 1-860-266-9966 (local
BEWARE OF SPURIOUS PHONE CALLS AND IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving
FICTITIOUS / FRAUDULENT OFFERS such phone calls are requested to lodge a police complaint


Thank you for choosing us to protect your loved ones.
Your decision to select Param Rakshak with return of rider premiums with a Life Cover of INR 1,50,00,000 will help secure the financial future of your loved ones as it comprises Tata AIA Life
Insurance's.
Smart Sampoorna Raksha, Accidental Death and Accidental Total & Permanent Disability, under Tata AIA Vitality Protect Plus.
This solution also offers a holistic wellness program-Tata AIA Vitality - which partners with you to help you focus on your physical and mental wellbeing while keeping you motivated with
various discounts and benefits.
Tata AIA Vitality - A Wellness Program that offers you an upfront discount at policy inception. You can also earn premium discount / cover booster (as applicable) for subsequent years on
policy anniversary basis your Vitality Status (tracked on Vitality app).
In case of death during the Policy Term, you are entitled to a life cover of INR 1,50,00,000 under the base plan (Tata AIA Life Insurance Smart Sampoorna Raksha). In case of no claims
during policy term, total premiums paid with respect to Accidental Death and Accidental Total & Permanent Disability, will be returned to you at Maturity.
Kindly refer to our benefit illustration here for all requisite details.
At Tata AIA Life Insurance, we are committed to help you live happier, healthier lives through solutions that provide Sampoorna Rakshakaran to your family so that you can be happy, with no
worries.
Best Wishes
Disclaimer: Param Rakshak ROP solution comprises of Tata AIA Life Insurance Smart Sampoorna Raksha, A Unit-linked, Non-participating, Individual Life Insurance Plan for Savings and
Protection (UIN: 110L156V02) and Tata AIA Vitality Protect Plus, A Non-linked, Non-participating, Individual Health Rider (UIN: 110A048V02). Insurance cover is available under the solution. |
The solution is underwritten by Tata AIA Life Insurance Company Ltd. This is not a guaranteed issuance solution and it will be subject to Company's underwriting and acceptance. | For more
details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale.
THE LINKED INSURANCE PRODUCT DO NOT OFFER ANY LIQUIDITY DURING THE FIRST FIVE YEARS OF THE CONTRACT. THE POLICY HOLDER WILL NOT BE ABLE TO
SURRENDER/WITHDRAW THE MONIES INVESTED IN LINKED INSURANCE PRODUCTS COMPLETELY OR PARTIALLY TILL THE END OF THE FIFTH YEAR.
Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati
Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd & AIA Group Ltd. & is used by Tata AIA Life Insurance Company Ltd under a license. For
any information including cancellation, claims & complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life's nearest branch office or call 1-860-266-9966 (local
BEWARE OF SPURIOUS PHONE CALLS AND IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving
FICTITIOUS / FRAUDULENT OFFERS such phone calls are requested to lodge a police complaint

BENEFIT ILLUSTRATION
Tata AIA Life Insurance Smart Sampoorna Raksha
Proposal No: U242922179
Name of the Prospect / Policyholder: Gautam Pratyush Name of the Product: Tata AIA Life Insurance Smart Sampoorna Raksha
Age (yrs) : 24 Tag Line : Unit-linked, Non-Participating, Individual Life Insurance Plan for Savings and Protection
Name of the Life Assured : Gautam Pratyush Unique Identification No.: 110L156V03
Age (yrs) : 24 GST Rate: 18.0%
Sum Assured (Rs.): 1,50,00,000 Investment Strategy Opted for: NIL
Policy Term (yrs): 40 Funds opted for along with their risk level
Premium Payment Term (yrs): 5 Fund Name Allocation Percentage Risk Profile
Amount of Instalment Premium (Rs.): 11,490 Large Cap Equity Fund (ULIF 017 07/01/08 TLC 110) 0%
Whole Life Mid-cap Equity Fund (ULIF 009 04/01/07 WLE 110) 20% High
Mode of Payment of Premium : Monthly
Whole Life Aggressive Growth Fund (ULIF 010 04/01/07 WLA 110) 0%
Whole Life Stable Growth Fund (ULIF 011 04/01/07 WLS 110) 0%
Whole Life Income Fund (ULIF 012 04/01/07 WLI 110) 0%
Whole Life Short Term Fixed Income Fund (ULIF 013 04/01/07 WLF 110) 0%
Multi Cap Fund (ULIF 060 15/07/14 MCF 110) 30% High
India Consumption Fund (ULIF 061 15/07/14 ICF 110) 30% High
Super Select Equity Fund (ULIF 035 16/10/09 TSS 110) 0%
Top 50 Fund (ULIF 026 12/01/09 ITF 110) 0%
Top 200 fund (ULIF 027 12/01/09 ITT 110) 20% High
Emerging Opportunities Fund (ULIF 064 12/09/22 EOF 110) 0%
Sustainable Equity Fund (ULIF 065 12/09/22 ESG 110) 0%
Dynamic Advantage Fund (ULIF 066 12/09/22 DAF 110) 0%
Flexi Growth Fund (ULIF 068 25/04/23 FGF 110) 0%
Constant Maturity Fund (ULIF 069 17/05/23 CMF 110) 0%
Target Maturity Fund (ULIF 070 17/05/23 TMF 110) 0%
Small Cap Discovery Fund (ULIF 071 22/05/23 SCF 110) 0%
Rider Details
Wellness Programme Yes Utilization of rewards (if Wellness program opted) Premium Discount
Rider Name/UIN^ (Benefit Details of Life Insured/Partner
Option/Benefit Payout Option) under the Benefit Option Benefit Payout
Return of Benefit Premium Sum Premium p.a. Year 1
premium Option Payment Assured without GST Discount
Age Lumpsum Income Income
Option Term Term (Rs.) (Rs.) (Rs.)
Name (yrs) Gender (Rs.) p.a. Duration
(Rs.) (yrs)
VPP - Accidental Death (Lumpsum Gautam 24 Male 5000000 0 0 Yes 40 5 5000000 16600 888
Benefit) Pratyush
VPP - Accidental Total & Gautam
Permanent Disability (Lumpsum Pratyush 24 Male 5000000 0 0 Yes 40 5 5000000 12100 636
Benefit)
^VPP - Tata AIA Vitality Protect Plus, (A Non - linked, Non - participating, Individual Health Rider, UIN: 110A048V02)
Premium Summary
Base Plan Riders Total Instalment Premium
Instalment Premium without GST (Rs.) 8,500 2,534 11,034
Instalment Premium with First year GST (Rs.) 8,500 2,990 11,490
Instalment Premium post applicable discount with First year GST (Rs.) 8,500 2,841 11,341
Instalment Premium with GST 2nd year onwards (Rs.) 8,500 2,990 11,490
Discount applicable and Installment Premium payable 2nd year onwards will depend on the Wellness status of the Insured
How to read and understand this benefit illustration?

This benefit illustration is intended to show what charges are deducted from your premiums and how the unit fund, net of charges and taxes, may grow over the years of the policy term if the
fund earns a gross return of 8% p.a. or 4% p.a. These rates, i.e., 8% p.a. and 4% p.a. are assumed only for the purpose of illustrating the flow of benefits if the returns are at this level. It should
not be interpreted that the returns under the plan are going to be either 8% p.a. or 4% p.a.
Net Yield mentioned corresponds to the gross investment return of 8% p.a., net of all charges but does not consider mortality, morbidity charges, underwriting extra, if any, guarantee charges
and cost of riders, if deducted by cancellation of units. It demonstrates the impact of charges and taxes on the net yield. Please note that the mortality charges per thousand sum assured in
general, increases with age.
The actual returns can vary depending on the performance of the chosen fund, charges towards mortality, morbidity, underwriting extra, cost of riders, etc. The investment risk in this policy is
borne by the policyholder, hence, for more details on terms and conditions please read sales literature carefully.
Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy offers guaranteed
benefits then these will be clearly marked "guaranteed" in the illustration table on this page. If your policy offers variable benefits then the illustration on this page will show two different rates
of assumed future investment returns, of 8% p.a. and 4% p.a. These assumed rates of return are not guaranteed and they are not the upper or lower limits of what you might get back, as the
value of your policy is dependant on a number of factors including future investment performance.
Part A of this statement presents a summary view of year-by-year charges deducted under the policy, fund value, surrender value and the death benefit, at two assumed rates of return. Part B of
this statement presents a detailed break-up of the charges, and other values.

Part A
(Amount in Rupees)
At 4% p.a. Gross Investment Return At 8% p.a. Gross Investment Return Commission
Annualized Mortality, Mortality, payable to
PolicyYear Premium Other Fund at End Surrender Other Fund at End Surrender intermediary
Morbidity GST Death Benefit Morbidity GST Death Benefit
Charges Charges* of Year Value Charges Charges* of Year Value (Rs.)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 1,02,041 11,793 12,724 4,413 74,648 69,363 1,50,00,000 11,793 12,732 4,414 76,201 70,806 1,50,00,000 0
2 1,02,041 11,705 7,562 3,468 1,58,616 1,53,800 1,50,00,000 11,703 7,608 3,476 1,64,923 1,60,107 1,50,00,000 0
3 1,02,041 11,638 7,573 3,458 2,46,015 2,42,403 1,50,00,000 11,630 7,699 3,479 2,60,729 2,57,116 1,50,00,000 0
4 1,02,041 11,604 6,613 3,279 3,38,112 3,35,752 1,50,00,000 11,588 6,867 3,322 3,65,285 3,62,925 1,50,00,000 0
5 1,02,041 11,631 9,680 3,836 4,30,168 4,30,168 1,50,00,000 11,603 10,111 3,909 4,74,205 4,74,205 1,50,00,000 0
6 0 11,773 10,379 3,987 4,20,693 4,20,693 1,50,00,000 11,730 11,033 4,097 4,84,177 4,84,177 1,50,00,000 0
7 0 12,041 10,523 4,061 4,10,343 4,10,343 1,50,00,000 11,981 11,417 4,211 4,94,168 4,94,168 1,50,00,000 0
8 0 12,394 10,669 4,151 3,98,976 3,98,976 1,50,00,000 12,315 11,813 4,343 5,04,060 5,04,060 1,50,00,000 0
9 0 12,861 10,713 4,243 3,86,536 3,86,536 1,50,00,000 12,760 12,119 4,478 5,13,820 5,13,820 1,50,00,000 0
10 0 13,416 10,557 4,315 3,97,597 3,97,597 1,50,00,000 13,290 12,236 4,595 5,48,045 5,48,045 1,50,00,000 0
11 0 14,062 10,818 4,478 4,19,787 4,19,787 1,50,00,000 13,906 12,790 4,805 5,95,775 5,95,775 1,50,00,000 0
12 0 14,805 11,082 4,659 4,39,433 4,39,433 1,50,00,000 14,613 13,377 5,038 6,43,509 6,43,509 1,50,00,000 0
13 0 15,683 11,314 4,859 4,54,310 4,54,310 1,50,00,000 15,448 13,963 5,294 6,89,088 6,89,088 1,50,00,000 0
14 0 16,687 11,487 5,071 4,62,175 4,62,175 1,50,00,000 16,400 14,522 5,566 7,30,252 7,30,252 1,50,00,000 0
15 0 17,846 11,574 5,295 4,68,908 4,68,908 1,50,00,000 17,497 15,025 5,854 7,72,775 7,72,775 1,50,00,000 0
16 0 19,152 11,647 5,544 4,74,537 4,74,537 1,50,00,000 18,728 15,545 6,169 8,16,811 8,16,811 1,50,00,000 0
17 0 20,617 11,707 5,818 4,79,097 4,79,097 1,50,00,000 20,105 16,084 6,514 8,62,535 8,62,535 1,50,00,000 0
18 0 22,268 11,754 6,124 4,82,512 4,82,512 1,50,00,000 21,650 16,644 6,893 9,10,023 9,10,023 1,50,00,000 0
19 0 24,153 11,786 6,469 4,84,706 4,84,706 1,50,00,000 23,406 17,226 7,314 9,59,362 9,59,362 1,50,00,000 0
20 0 26,297 11,802 6,858 4,85,514 4,85,514 1,50,00,000 25,395 17,830 7,780 10,10,559 10,10,559 1,50,00,000 0
21 0 28,761 11,800 7,301 4,84,701 4,84,701 1,50,00,000 27,672 18,455 8,303 10,63,563 10,63,563 1,50,00,000 0
22 0 31,636 11,776 7,814 4,81,931 4,81,931 1,50,00,000 30,318 19,101 8,895 11,18,228 11,18,228 1,50,00,000 0
23 0 34,981 11,726 8,407 4,76,867 4,76,867 1,50,00,000 33,381 19,766 9,566 11,74,414 11,74,414 1,50,00,000 0
24 0 38,888 11,646 9,096 4,69,032 4,69,032 1,50,00,000 36,941 20,447 10,330 12,31,854 12,31,854 1,50,00,000 0
25 0 43,432 11,528 9,893 4,57,907 4,57,907 1,50,00,000 41,059 21,141 11,196 12,90,247 12,90,247 1,50,00,000 0
26 0 48,659 11,366 10,804 4,42,890 4,42,890 1,50,00,000 45,763 21,844 12,169 13,49,214 13,49,214 1,50,00,000 0
27 0 54,599 11,154 11,835 4,23,352 4,23,352 1,50,00,000 51,068 22,551 13,251 14,08,360 14,08,360 1,50,00,000 0
28 0 61,252 10,882 12,984 3,98,701 3,98,701 1,50,00,000 56,956 23,257 14,438 14,67,329 14,67,329 1,50,00,000 0
29 0 68,542 10,547 14,236 3,68,517 3,68,517 1,50,00,000 63,341 23,960 15,714 15,25,938 15,25,938 1,50,00,000 0
30 0 76,418 10,142 15,581 3,32,484 3,32,484 1,50,00,000 70,157 24,657 17,066 15,84,121 15,84,121 1,50,00,000 0
31 0 84,774 9,666 16,999 2,90,527 2,90,527 1,50,00,000 77,288 25,350 18,475 16,42,054 16,42,054 1,50,00,000 0
32 0 93,340 9,462 18,504 2,95,140 2,95,140 1,50,00,000 84,636 26,042 19,922 17,00,216 17,00,216 1,50,00,000 0
33 0 1,01,908 9,652 20,081 3,13,097 3,13,097 1,50,00,000 92,103 26,741 21,392 17,59,336 17,59,336 1,50,00,000 0
34 0 1,10,604 9,885 21,688 3,33,778 3,33,778 1,50,00,000 99,647 27,457 22,879 18,20,405 18,20,405 1,50,00,000 0
35 0 1,19,412 10,155 23,322 3,57,565 3,57,565 1,50,00,000 1,07,244 28,203 24,380 18,84,633 18,84,633 1,50,00,000 0
36 0 1,28,358 10,466 24,988 3,84,913 3,84,913 1,50,00,000 1,14,907 28,994 25,902 19,53,350 19,53,350 1,50,00,000 0
37 0 1,37,566 10,825 26,710 4,16,364 4,16,364 1,50,00,000 1,22,736 29,846 27,465 20,27,882 20,27,882 1,50,00,000 0
38 0 1,47,153 11,240 28,511 4,52,564 4,52,564 1,50,00,000 1,30,824 30,775 29,088 21,09,491 21,09,491 1,50,00,000 0
39 0 1,57,310 11,718 30,425 4,94,280 4,94,280 1,50,00,000 1,39,321 31,795 30,801 21,99,157 21,99,157 1,50,00,000 0
40 0 1,68,213 12,272 32,487 5,42,433 5,42,433 1,50,00,000 1,47,608 33,710 32,637 23,72,158 23,72,158 1,50,00,000 0
*Other charges includes Premium Allocation Charge, Policy Admin Charge, Fund Management Charge and Rider Charges, if any. See Part B for details.
IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICYHOLDER AND THE ABOVE INTEREST RATES ARE ONLY FOR ILLUSTRATIVE PURPOSE.
I ............ (name), have explained the premiums, charges and benefits under the I ............ (name), having received the information with respect to the above, have understood the
policy fully to the prospect / policyholder. above statement before entering into the contract.
Place:
Date: Signature of Agent/ Intermediary/ Official Date: Signature of Prospect/ Policyholder

Part B
Gross Yield 8% p.a Net Yield 7.78% Amount in Rupees
Premium Annualized
Annualized Premium —
PolicyYear Premium Allocation Premium Mortality GST PolicyAdmin Guarantee Rider Additions to Fund before FMC Fund at End Surrender Death
(AP) Charge Allocation charge Charge Charge Charges the Fund* FMC of Year Value Benefit
(PAC)
Charges
1 1,02,041 12,240 89,801 11,793 4,414 0 0 0 0 76,291 491 76,201 70,806 1,50,00,000
2 1,02,041 6,120 95,921 11,703 3,476 0 0 0 0 1,65,118 1,487 1,64,923 1,60,107 1,50,00,000
3 1,02,041 5,100 96,941 11,630 3,479 0 0 0 0 2,61,037 2,599 2,60,729 2,57,116 1,50,00,000
4 1,02,041 3,060 98,981 11,588 3,322 0 0 0 0 3,65,717 3,806 3,65,285 3,62,925 1,50,00,000
5 1,02,041 0 1,02,041 11,603 3,909 5,020 0 0 0 4,74,766 5,091 4,74,205 4,74,205 1,50,00,000
6 0 0 0 11,730 4,097 5,271 0 0 0 4,84,749 5,761 4,84,177 4,84,177 1,50,00,000
7 0 0 0 11,981 4,211 5,535 0 0 0 4,94,752 5,881 4,94,168 4,94,168 1,50,00,000
8 0 0 0 12,315 4,343 5,812 0 0 0 5,04,656 6,001 5,04,060 5,04,060 1,50,00,000
9 0 0 0 12,760 4,478 6,000 0 0 0 5,14,427 6,119 5,13,820 5,13,820 1,50,00,000
10 0 0 0 13,290 4,595 6,000 0 0 24,480 5,24,184 6,236 5,48,045 5,48,045 1,50,00,000
11 0 0 0 13,906 4,805 6,000 0 0 35,826 5,82,262 6,790 5,95,775 5,95,775 1,50,00,000
12 0 0 0 14,613 5,038 6,000 0 0 33,605 6,32,110 7,376 6,43,509 6,43,509 1,50,00,000
13 0 0 0 15,448 5,294 6,000 0 0 29,381 6,81,840 7,962 6,89,088 6,89,088 1,50,00,000
14 0 0 0 16,400 5,566 6,000 0 0 23,177 7,29,187 8,521 7,30,252 7,30,252 1,50,00,000
15 0 0 0 17,497 5,854 6,000 0 0 23,206 7,71,758 9,024 7,72,775 7,72,775 1,50,00,000
16 0 0 0 18,728 6,169 6,000 0 0 23,461 8,15,819 9,545 8,16,811 8,16,811 1,50,00,000
17 0 0 0 20,105 6,514 6,000 0 0 23,961 8,61,555 10,084 8,62,535 8,62,535 1,50,00,000
18 0 0 0 21,650 6,893 6,000 0 0 24,629 9,09,044 10,644 9,10,023 9,10,023 1,50,00,000
19 0 0 0 23,406 7,314 6,000 0 0 25,520 9,58,367 11,226 9,59,362 9,59,362 1,50,00,000
20 0 0 0 25,395 7,780 6,000 0 0 26,580 10,09,536 11,829 10,10,559 10,10,559 1,50,00,000
21 0 0 0 27,672 8,303 6,000 0 0 27,812 10,62,502 12,455 10,63,563 10,63,563 1,50,00,000
22 0 0 0 30,318 8,895 6,000 0 0 29,226 11,17,114 13,101 11,18,228 11,18,228 1,50,00,000
23 0 0 0 33,381 9,566 6,000 0 0 30,897 11,73,227 13,766 11,74,414 11,74,414 1,50,00,000
24 0 0 0 36,941 10,330 6,000 0 0 32,801 12,30,577 14,447 12,31,854 12,31,854 1,50,00,000
25 0 0 0 41,059 11,196 6,000 0 0 34,993 12,88,855 15,141 12,90,247 12,90,247 1,50,00,000
26 0 0 0 45,763 12,169 6,000 0 0 37,456 13,47,687 15,844 13,49,214 13,49,214 1,50,00,000
27 0 0 0 51,068 13,251 6,000 0 0 40,210 14,06,674 16,551 14,08,360 14,08,360 1,50,00,000
28 0 0 0 56,956 14,438 6,000 0 0 43,299 14,65,455 17,257 14,67,329 14,67,329 1,50,00,000
29 0 0 0 63,341 15,714 6,000 0 0 46,811 15,23,842 17,959 15,25,938 15,25,938 1,50,00,000
30 0 0 0 70,157 17,066 6,000 0 0 50,791 15,81,762 18,657 15,84,121 15,84,121 1,50,00,000
31 0 0 0 77,288 18,475 6,000 0 0 55,345 16,39,385 19,350 16,42,054 16,42,054 1,50,00,000
32 0 0 0 84,636 19,922 6,000 0 0 60,635 16,97,175 20,042 17,00,216 17,00,216 1,50,00,000
33 0 0 0 92,103 21,392 6,000 0 0 66,763 17,55,855 20,741 17,59,336 17,59,336 1,50,00,000
34 0 0 0 99,647 22,879 6,000 0 0 73,883 18,16,403 21,456 18,20,405 18,20,405 1,50,00,000
35 0 0 0 1,07,244 24,380 6,000 0 0 82,118 18,80,021 22,202 18,84,633 18,84,633 1,50,00,000
36 0 0 0 1,14,907 25,902 6,000 0 0 91,526 19,48,036 22,993 19,53,350 19,53,350 1,50,00,000
37 0 0 0 1,22,736 27,465 6,000 0 0 1,02,136 20,21,773 23,846 20,27,882 20,27,882 1,50,00,000
38 0 0 0 1,30,824 29,088 6,000 0 0 1,13,913 21,02,498 24,775 21,09,491 21,09,491 1,50,00,000
39 0 0 0 1,39,321 30,801 6,000 0 0 1,26,682 21,91,207 25,794 21,99,157 21,99,157 1,50,00,000
40 0 0 0 1,47,608 32,637 6,000 0 0 2,09,811 23,63,277 27,710 23,72,158 23,72,158 1,50,00,000

Gross Yield 4% p.a Amount in Rupees
Premium Annualized
Annualized Allocation Premium — Mortality PolicyAdmin Guarantee Rider Additions to Fund before Fund at End Surrender Death
PolicyYear Premium Charge Premium charge GST Charge Charge Charges the Fund* FMC FMC of Year Value Benefit
(AP) Allocation
(PAC) Charges
1 1,02,041 12,240 89,801 11,793 4,413 0 0 0 0 74,737 484 74,648 69,363 1,50,00,000
2 1,02,041 6,120 95,921 11,705 3,468 0 0 0 0 1,58,804 1,441 1,58,616 1,53,800 1,50,00,000
3 1,02,041 5,100 96,941 11,638 3,458 0 0 0 0 2,46,306 2,472 2,46,015 2,42,403 1,50,00,000
4 1,02,041 3,060 98,981 11,604 3,279 0 0 0 0 3,38,511 3,553 3,38,112 3,35,752 1,50,00,000
5 1,02,041 0 1,02,041 11,631 3,836 5,020 0 0 0 4,30,676 4,659 4,30,168 4,30,168 1,50,00,000
6 0 0 0 11,773 3,987 5,271 0 0 0 4,21,190 5,107 4,20,693 4,20,693 1,50,00,000
7 0 0 0 12,041 4,061 5,535 0 0 0 4,10,827 4,987 4,10,343 4,10,343 1,50,00,000
8 0 0 0 12,394 4,151 5,812 0 0 0 3,99,447 4,856 3,98,976 3,98,976 1,50,00,000
9 0 0 0 12,861 4,243 6,000 0 0 0 3,86,993 4,713 3,86,536 3,86,536 1,50,00,000
10 0 0 0 13,416 4,315 6,000 0 0 24,480 3,73,558 4,557 3,97,597 3,97,597 1,50,00,000
11 0 0 0 14,062 4,478 6,000 0 0 35,827 4,06,065 4,818 4,19,787 4,19,787 1,50,00,000
12 0 0 0 14,805 4,659 6,000 0 0 33,611 4,27,791 5,081 4,39,433 4,39,433 1,50,00,000
13 0 0 0 15,683 4,859 6,000 0 0 29,396 4,46,783 5,313 4,54,310 4,54,310 1,50,00,000
14 0 0 0 16,687 5,071 6,000 0 0 23,208 4,60,790 5,486 4,62,175 4,62,175 1,50,00,000
15 0 0 0 17,846 5,295 6,000 0 0 23,261 4,67,527 5,573 4,68,908 4,68,908 1,50,00,000
16 0 0 0 19,152 5,544 6,000 0 0 23,546 4,73,132 5,646 4,74,537 4,74,537 1,50,00,000
17 0 0 0 20,617 5,818 6,000 0 0 24,081 4,77,653 5,707 4,79,097 4,79,097 1,50,00,000
18 0 0 0 22,268 6,124 6,000 0 0 24,788 4,81,013 5,753 4,82,512 4,82,512 1,50,00,000
19 0 0 0 24,153 6,469 6,000 0 0 25,722 4,83,132 5,785 4,84,706 4,84,706 1,50,00,000
20 0 0 0 26,297 6,858 6,000 0 0 26,833 4,83,848 5,802 4,85,514 4,85,514 1,50,00,000
21 0 0 0 28,761 7,301 6,000 0 0 28,124 4,82,928 5,800 4,84,701 4,84,701 1,50,00,000
22 0 0 0 31,636 7,814 6,000 0 0 29,609 4,80,031 5,776 4,81,931 4,81,931 1,50,00,000
23 0 0 0 34,981 8,407 6,000 0 0 31,366 4,74,814 5,726 4,76,867 4,76,867 1,50,00,000
24 0 0 0 38,888 9,096 6,000 0 0 33,374 4,66,803 5,645 4,69,032 4,69,032 1,50,00,000
25 0 0 0 43,432 9,893 6,000 0 0 35,692 4,55,471 5,527 4,57,907 4,57,907 1,50,00,000
26 0 0 0 48,659 10,804 6,000 0 0 38,303 4,40,218 5,366 4,42,890 4,42,890 1,50,00,000
27 0 0 0 54,599 11,835 6,000 0 0 41,235 4,20,412 5,153 4,23,352 4,23,352 1,50,00,000
28 0 0 0 61,252 12,984 6,000 0 0 44,537 3,95,457 4,882 3,98,701 3,98,701 1,50,00,000
29 0 0 0 68,542 14,236 6,000 0 0 48,305 3,64,922 4,546 3,68,517 3,68,517 1,50,00,000
30 0 0 0 76,418 15,581 6,000 0 0 52,593 3,28,489 4,141 3,32,484 3,32,484 1,50,00,000
31 0 0 0 84,774 16,999 6,000 0 0 57,522 2,86,071 3,665 2,90,527 2,90,527 1,50,00,000
32 0 0 0 93,340 18,504 6,000 0 0 1,14,624 2,86,762 3,461 2,95,140 2,95,140 1,50,00,000
33 0 0 0 1,01,908 20,081 6,000 0 0 1,37,683 3,03,895 3,651 3,13,097 3,13,097 1,50,00,000
34 0 0 0 1,10,604 21,688 6,000 0 0 1,50,182 3,23,743 3,885 3,33,778 3,33,778 1,50,00,000
35 0 0 0 1,19,412 23,322 6,000 0 0 1,63,120 3,46,690 4,154 3,57,565 3,57,565 1,50,00,000
36 0 0 0 1,28,358 24,988 6,000 0 0 1,76,589 3,73,189 4,465 3,84,913 3,84,913 1,50,00,000
37 0 0 0 1,37,566 26,710 6,000 0 0 1,90,808 4,03,770 4,825 4,16,364 4,16,364 1,50,00,000
38 0 0 0 1,47,153 28,511 6,000 0 0 2,06,006 4,39,066 5,239 4,52,564 4,52,564 1,50,00,000
39 0 0 0 1,57,310 30,425 6,000 0 0 2,22,511 4,79,826 5,718 4,94,280 4,94,280 1,50,00,000
40 0 0 0 1,68,213 32,487 6,000 0 0 2,40,662 5,26,953 6,271 5,42,433 5,42,433 1,50,00,000
Notes:
1. Refer the sales literature for explanation of terms used in this illustration.
2. Fund management charge is based on the specific fund option(s) chosen.
3. *Additions to the Fund refers to the periodic additions through A) Refund of 2X Mortality Charges, B) Refund of 2X Premium Allocation Charges and C) Cover Continuance Booster.
"Income Tax benefits would be available as per the prevailing income tax laws, subject to fulfillment of conditions stipulated therein. Tata AIA Life Insurance Company Ltd. does not assume
responsibility on tax implication mentioned anywhere in this document. Please consult your own tax consultant to know the tax benefits available to you."
The rider sum assured shall remain unchanged for a period as specified under ‘Guaranteed Period’ from the Date of Commencement of the benefit option. Upon the completion of
Guaranteed Period’, the sum assured as applicable for the benefit option may be revised or the policyholder may be given an option of top up premium to restore the benefit to original
amount, subject to IRDAI’s approval. The top up premium may be payable as a single premium/ level premium during the block of next guarantee period. The requirement of paying the Top
up premium in order to continue with the current level of benefit may be applicable even after expiry of limited pay premium term.
I ........... (name), have explained the premiums, charges and benefits under the I ........... (name), having received the information with respect to the above, have understood the
policy fully to the prospect / policyholder. above statement before entering into the contract.
Place:
Date: ....... Signature of Agent/ Intermediary/ Official Date:......... Signature of Prospect/ Policyholder
Unique Reference Number -L&C/Advt/2023/Sep/2912 (Rider- L&C/Advt/2022/Sep/2271)
Tata AIA Life Insurance Company Ltd. (IRDA of India Regn No. 110) (CIN: U66010MH2000PLC128403)
Registered and Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai- 400013
Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance Company Ltd under a license.
For more information, Call the Tata AIA Life Insurance Company Ltd Helpline number1860-266-9966 (local charges apply) or Visit us at: www.tataaia.com

PIVC Video of U242922179 is uploaded on SFTP of TATA AIA

COVID-19 (Coronavirus) Exposure Questionnaire
Name Of Proposed Insured : Gautam Pratyush
Policy no: U242922179 Dated: 14-Nov-2023
Please answer the following questions in as much detail as possible:

1. Have you been in close contact with anyone who has been quarantined (including your family members)
or who has been diagnosed with novel coronavirus (SARS-CoV-2/COVID-19) within the last three Yes No
weeks?
• If yes, then please confirm if you had any COVID 19 symptoms?
2. Have you been advised to be tested to rule in or rule out, a diagnosis of novel coronavirus Yes No
(SARSCoV-2/COVID-19)?
• If yes, then please confirm status
Test Result Received Awaiting Test Results Not Yet Tested
If you have received the Test Result, it is mandatory answer to sub questions a and b
a. Date of Last COVID 19 result -
b. Result of Last COVID 19 test -
c. Did you require,
Admission to hospital Home Quarantine/Isolation Not Required
i. If Hospitalized:
- Date of Admission
- Date of Discharge
- Did you require treatment in the Intensive Care unit (ICU) and/or a machine Yes No
[ventilator support]to help you breathe?
- Did you experience any complication(s) related to lungs, Kidney, liver or heart problems(s)? Yes No
ii. If home quarantine / Isolation,
- Please specify the last date of home quarantine / Isolation -
3. If Question no 2 is answered as "Yes", then please answer below questions a and b"
a. Do you currently experience or did you had any recurrence of symptoms related to COVID 19 infection?
b. Do you have any pending or recommended follow-up appointments or tests related to COVID-19 Yes No
diagnosis? Yes No
4. Are you a Healthcare professional (Includes Doctors, Nurses, Pathologist, Paramedics, Pharmacist, Yes No
Ward helpers) & enrolled as Corona warrior or working in Hospitals/ Clinics with novel coronavirus
(SARS-CoV-2/COVID-19) ward/unit or treating/in contact with COVID-19 infected individuals?

5. Travel Declaration
a. Have you travelled outside of India in the past 3 weeks? If Yes, please provide your travel details Yes No
over the past 3 weeks:
COUNTRY DATE ARRIVED DATE DEPARTED
b. Do you intend to travel Outside of India in next 3 months: If Yes, Please provide details of your Yes No
intended future travel within next 3 months:
COUNTRY DATE of TRAVEL INTENDED DURATION
6. Have you been vaccinated for COVID19?

Yes No
If yes , Please provide your details:
Date of administration of the first dose (Non-Mandatory)
Date of administration of the second dose (Non-Mandatory)
Have you experienced any adverse reaction post vaccination? Yes No
If yes, please share details including treatment taken for the same and date of complete recovery
Declaration
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material
information that may influence the assessment or acceptance of this application.
I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any material fact
known to me may invalidate my insurance(s)
Signature of Gautam Pratyush Date: 14-Nov-2023
Proposed insured
Signature of
Applicant:
(If applicant is different Date:
from the Proposed
insured)
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. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA
Life Insurance Company Ltd under a license. For any information including cancellation, claims and complaints, please
contact our Insurance Advisor / Intermediary or visit Tata AIA Life's nearest branch office or call 1-860-266-9966 (local
charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.• L&C/Misc/2021/Sep/0449.
RDAI is not involved in activities like selling insurance policies, announcing bonus or
BEWARE OF SPURIOUS/
FRAUD PHONE CALLS! investment of premiums. Public receiving such phone calls are requested to lodge a police
complaint.

Medical Examination Report
Transcript of the Telephony Medical Examination Report (TMER)
This is the transcript of the answers provided by Life to be assured verbally to the questions asked below in a telephonic verification by the underwriting
team of Tata AIA Life Insurance Company Ltd. The answers provided by the Life to be assured would form a part of the application for insurance.
We request you to go through the transcript carefully. In case of any disagreement, you are requested to highlight the same within 15 days of the
receipt of this transcript; otherwise this would be taken as acceptable to you and thereby binding on you. Please retain this transcript for future
reference.
Application No. U242922179 Date 14-Nov-2023
Life to be Assured (LA) Mr Gautam Pratyush Contact No. 9199878315
Date of Birth 15-Oct-1999 Gender MALE
ID Details BMI 30.17
These are the following questions, along with their answers, that were asked during the examination:
YES NO IF YES, please give details
Occupation
- Self-employed
2 Your current Occupation Yes
Remarks
3 Your annual income Yes 7LPA
4 Please show your ID proof Yes PAN CARD-EFXPP1591H
5 Kindly share your current location( City and state with country)? Yes Patna, Bihar, India
6 Are you currently in Good Health ? Yes
7 Are you taking any type of medication currently? No
8 Height Yes 172.72
9 Weight Yes 90
Did you have any loss or gain of weight of 10 kg or more in the last
10 No
six months?
Have you ever in the past consumed or currently consume tobacco

11 No
in any form like Cigarette,Bidi,Pan,Gutkha?
12 Have you ever in the past or are currently consuming Narcotics? No
Have you ever been diagnosed and treated for any of following
13 conditions or are currently being treated or underwent surgery for No
Diabetes,high blood sugar
High blood pressure,Hypertension ,Elevated Cholesterol,Lipids?
conditions or are currently being treated or underwent surgery for
15 No
Chest pain, heart attack, palpitation, any other heart disease or
circulatory disease?
16 Have you ever been diagnosed and treated for any of following No
conditions or are currently being treated or underwent surgery for

Any lung,respiratory Disease or Urine,Kidney disease or any
Liver ,gastric disorders?
Cancer or tumor of any kind?
Do you or your spouse has been tested positive or is under

18 treatment for HIV , AIDS or Sexually transmitted diseases (e.g. No
syphilis, gonorrhea, etc.)?
Any Accidental injury,Disability?
Do you have any other health condition or are you currently/in

20 past were under any treatment for any health condition not No
covered above?
Have you undergone any investigations like blood ,urine test , X-

21 No
ray , ECG or any special test such as TMT, CT scan, MRI?
Have you ever been hospitalized for any illness, sickness, disease,
22 No
injury, accident or disorder in the last 5 years?
[For Male]Have you ever been diagnosed &/OR treated for

23 Prostate related disorder or been under follow up for the same No
with PSA test, USG pelvis etc.
24 [For Female] Are you currently pregnant ? No
[For Female] Have you undergone any gynaecological

25 investigations for any problems of breast , uterus , cervix etc.Have No
you done or advised for any Pap smear, mammogram?
[For Female] Have you ever consulted a doctor because of an

irregularity at the breast, vagina, uterus, ovary, fallopian tubes,
26 No
menstruation, complications during pregnancy or child delivery or
a sexually transmitted disease?
Covid Diagnosis
- >1 month ago Diagnosed & Home Quarantined

Have you ever been hospitalized due to Covid, and have come into Remarks
27 close contact with a Covid positive patient or suffered any Covid Yes
symptoms in the last 30 days? - LA tested positive in 2021 complained of fever and
cough, no hospitalisation, home isolated for 4-5 days, no
complications, no breathing difficulty, recovered in 10
days came negative in 10 days
Is there anything else that you would like to share with us with
respect to your health,habits or anything else that you believe is
28 No
important to ensure that policy is processed basis all facts &
information?
DECLARATION:
You Gautam Pratyush, declare that, you have fully understood the questions asked to you as per this call and have furnished complete, true and accurate
information after fully understanding the same.
Sir/Mam' are you in agreement with the declaration that I have read out to you.
Wethankyouforhavingtakenthetimetoconfirmthedetails.Wewillprocessyourproposalbasedon theinformationprovided.
Name and Signature of the Medical Doctor/ Medical Underwriter
Dr. Pulkit Gupta

Reg no:
Dated Time of Medical Verification 14/11/2023 16:18

UNIT STATEMENT
IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT
PORTPOLIO IS BORNE BY THE POLICYHOLDER
Product Name Tata AIA Life Insurance Smart Sampoorna Raksha (UIN - 110L156V03)
Policy No U242922179
Policy Date 18/11/ 2023
Next Due date 18/12/ 2023
Basic Policy Premium(`) 8500.00
Rider Premium(`) 2407.00
Service Tax on Rider Premium(`) 433.26
Policy Term 40
Premium Paying Term 5
Mode Monthly
Insured Name Gautam Pratyush
Owner Name Gautam Pratyush
Section 1: FUND VALUE AS AT 20 /11/2023

Regular/Single Top-Up Regular/Single Premium
Net Asset Top-Up Premium Account Surrender
Premium Premium Account
Fund Portfolio Value(`) Units Fund Value(`) Units Fund Value(`) Value(`)
Account Account
Allocation Allocation (A) (B) C=(A*B) (D) E=(A*D) (F)
India Consumption Fund (ULIF 061
30.00% 0.00% 44.9052 40.980109 1840.22 0.000000 0.00 1659.74
15/07/14 ICF 110)
Multi Cap Fund (ULIF 060 15/07/14
30.00% 0.00% 49.2052 37.398893 1840.22 0.000000 0.00 1675.51
MCF 110)
Top - 200 Fund (ULIF 027 12/01/09
20.00% 0.00% 130.9169 9.370982 1226.82 0.000000 0.00 1185.54
ITT 110)
Whole Life Mid Cap Equity Fund
20.00% 0.00% 112.9759 10.859131 1226.82 0.000000 0.00 1178.99
(ULIF 009 04/01/07 WLE 110)
TOTAL 100.00% 0.00% 6134.08 0.00 5699.78
Section 2: PREMIUM INFORMATION IN THE CURRENT POLICY YEAR (2023-2023)

Regular/Single Premium Top-Up Premium
Premium Details
Current Policy Year (`) Since Inception(`) Current Policy Year(`) Since Inception(`)
Total Premium(s) Paid 8500.00 8500.00 0.00 0.00
Total Premium(s) Invested 7296.40 7296.40 0.00 0.00
BREAKUP OF TOTAL CHARGES DEDUCTED IN THE CURRENT POLICY YEAR

Charge Details Regular/Single Premium (`) Top-Up Premium (`)
Total Premium Allocation Charges 1020.00 0.00
Service Tax on Premium Allocation Charge 183.60 0.00
Total Mortality Charges on Sum Assured (985.02) 0.00
Service Tax on Mortality Charges on Sum Assured (177.30) 0.00

Section 3: COVERAGE INFORMATION DETAILS
Benefit Type Sum Assured (`) Effective Date Expiry Date
Basic Sum Assured 15000000.00 Nov 18, 2023 Nov 18, 2063
Total Top-up Sum Assured 0.00
Current Death Benefit (Regular / Single Premium Account) as at 20 /11/2023 (`) 15000000.00
Current Death Benefit (Top-up Premium Account) as at 20 /11/2023 (`) .00
Total Death Benefit as at 20 /11/2023 * (`) 15000000.00
* Please refer to the Policy Contract on Death Benefit. It does not include any Supplementary Benefit with Death Coverage.
Unit Pricing methodology under Unit Linked Life insurance products has undergone changes pursuant to IRDA of India Circular ref:
IRDA/F&I/ CIR/INV/173/08/2011 dated 29th July, 2011. Policyholders are informed that effective from 16th August, 2011 we have
started calculating unit prices as per the procedure prescribed in the above Circular as amended/modified by IRDA of India from time
to time. There is no change in the number of units to the credit of any policyholder on account of this change.
**In case of Complete Withdrawal within the first five years of the policy, the proceeds of the Discontinued Policy shown in the Unit
Statement shall be paid to the policyholder post completion of the lock-in period of five years from the inception of the policy or on
death of the insured, if earlier.
“Proceeds of the Discontinued Policy” means the fund value as on the date of discontinuance plus entire income earned after
deduction of the fund management charges, subject to a minimum guarantee of interest @ 4% p.a. or as prescribed by IRDA of India
from time to time.
Contact Us:
Contact Us:
SMS 'HELP' to 5676799 for list of services offered via SMS'SERVICE' to 58888 to receive call back from our Customer Service Executives
Website www.tataaia.com Log on to the Customer Portal
Email customercare@tataaia.com
Call Center Helpline No.-1800-267-9966 (Toll Free)1860-266-9966 (Local ChargesApply) Callers Outside India 080-67603700 (Charges apply)
Write us to Tata AIA Life Insurance Company Ltd.

14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013
Kindly Note:
l Investment Risk in the investment portfolio shall be solely borne by the policyholder. The premium paid in Unit Linked Life
Insurance policies are subject to investment risks associated with capital markets and the NAVs of the units may go up or down
based on the performance of the fund and factors infiuencing the capital market and the insured shall be responsible for his or her
decision.
l The underlying Fund’s Unit Price will be affected by interest rates and the performance of the underlying stocks. The Fund’s
Unit Price may goup or down refiecting the market value of the underlying assets.
l Please know the associated risks and the applicable charges, from your insurance agent or the Intermediary or policy
document issued by theinsurance company.
l Whilst every care has been taken in the preparation of this statement, it is subject to correction and this statement should be
read along with the policy document and does not individually confer any legal rights. For policy terms and conditions, please refer to
the policy document.
l This statement shall form a part of the policy document.
l As this is a computer generated statement, no signature is required.
l Service tax is applicable as per governing laws and the same shall be borne by the policyholder. Tata AIA Life Insurance
Company Limitedreserves the right to recover from the Policyholder, any levies and duties (including service tax), as imposed by the
goverment from time to time.
l Insurance cover is available under this product.
l For policy terms and conditions, please refer to the policy document. (Unique Reference No: L&C/Advt/2014/Mar/159)

FIRST PREMIUM RECEIPT
PERSONAL DETAILS
Policy Number: U242922179 Plan Name:
Sampoorna Raksha (110L156V03)
Policy Owner Name: Gautam Pratyush Life Assured Name: Gautam Pratyush
POLICYBAZAAR INSURANCE
Email ID: GPSK3099@GMAIL.COM Distributor/Agent Name:
BROKERS PRIVATE LIMITED
Contact No. : 9199878315 Distributor/Agent Contact Number: 18002585970
PAN Details EFXPP1591H
PREMIUM DETAILS
Premium Amount Due (In Rs.) 10907.00 Payment Mode Monthly
Goods & Service Tax (GST) 433.00 Next Premium Due on 18/12/2023
Total Amount (In Rs.) (a) 11340.00 Excess Amount (In Rs.) (b-a) 1.00
Amount Received (In Rs.) (b) 11,341.00
TAX BENEFIT DETAILS

Sec 80 C Sec 80 CCC Sec 80 D
10142.00 .00 1198.00
PAYMENT DETAILS
Receipt Number Receipt Date Amount (In Rs.) Payment Method
PP1657832 14/11/2023 11,341.00 Online Payment
Please Note:
l This document can be used as a proof for claiming deduction while filling your tax returns and tax benefits would be applicable as per
the prevailing tax laws.
l Payments made through modes other than cash are subject to clearance including through electronic mode payments.
l Any excess premium will be adjusted towards premium due in the current financial year or due in the next three months, whichever is later. Else
premium will be auto refunded post 15 days.
l Applicable govt taxes, surcharge, cess including GST would be charged in accordance with applicable Laws and Company will have the right to
recover the same from the policyholder.
l Please refer to the policy document for detailed terms and conditions and our website for FAQ on applicable tax benefits.
l In case of Unit Linked Policy (ULIP), if premium is received by us after 3:00 pm on a business day, NAV of the next business day shall apply.
GST DETAILS
Base Premium Taxable Value CGST .00% SGST/UTGST .00% IGST 18.00% Reverse Charge
` 10907.00 ` 2407.00 ` .00 ` .00 ` 433.00
Tata AIA Life Insurance Tata AIA Life Insurance GST
HARYANA 06AABCT3784C1ZH SAC Description Life Insurance
State IN
Policy Owner's GST State BIHAR Policy Owner's GSTIN SAC Code 997132
Consolidated Revenue stamp duty paid: Notification No. Mudrank – LOA NO.CSD/131/2023/ (Validity period from dated 29-09-2023 to
24-09-2024)/4009 Dated 04-10-2023 vide receipt number MH008113190202324E dated on 15-09-2023.
PAN: AABCT3784C.

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Gautam Pratyush

MU01 U242922179 SP 2151/2166 BROK Non Term_EIA

Life Insurance Cover Life Insurance Cover

Accidental Death Benefit Accidental Death Benefit

Criticare Plus Benefit

MU01 U242922179 SP 2151/2166 BROK Non Term_EIA

Dear Gautam Pratyush ,

Thank you for choosing us to protect your loved ones.

Tata AIA Life Insurance Company Limited

Policy Servicing Branch : 101-Boston house,Suren Road,Nr, Western Highway,Andheri E - 400093

#RakshakaranKiReet Go to Table of Contents 3/49

MU01 U242922179 SP 2151/2166 BROK Non Term_EIA

Dear Gautam Pratyush,

We look forward to a long and cherished relationship with you. ¬nn¬-Hrj¡¤WfqTi¬14-¬nn¬

Scan the QR to download e-policy document

CLICK HERE TO READ THE TERMS AND CONDITIONS

Policy Servicing Branch : 101-Boston house,Suren Road,Nr, Western Highway,Andheri E - 400093

#RakshakaranKiReet Go to Table of Contents 4/49

Tata AIA Life Insurance Smart Sampoorna Raksha (UIN: 110L156V03)

LIFE INSURED Gautam Pratyush

This is a system generated document requiring no physical signature.

#RakshakaranKiReet Go to Table of Contents 5/49

MU01 U242922179 SP 2151/2166 BROK Non Term_EIA

Tata AIA Vitality Protect Plus (UIN: 110A048V02)

We look forward to a long and cherished relationship with you.

Policy Servicing Branch : 101-Boston house,Suren Road,Nr, Western Highway,Andheri E - 400093

#RakshakaranKiReet Go to Table of Contents 6/49

Tata AIA Vitality Protect Plus (UIN: 110A048V02)

Tata AIA Life Insurance Company Limited

INSURED Gautam Pratyush

Tata AIA Life Insurance Company Limited

This is a system generated document requiring no physical signature.

CLICK HERE TO READ TERMS AND CONDITIONS

#RakshakaranKiReet Go to Table of Contents 7/49

Policy schedule Detailed overview of your registered policy 9

List of the beneficial features that comprise

Range of customer-centric services offered by

A pre-investment, agreed-upon form that

An illustrative way of presenting year-wise

Record of all transactions that occur with the

Acknowledgement of the first premium

#RakshakaranKiReet Go to Table of Contents 8/49

Modal Total Modal

Applicable Target Gross Reduction-in-Yield (TGRIY)

Nominee details (under section 39 of the Insurance Act 1938)

Appointee details (Applicable in case the Nominee is a minor)

#RakshakaranKiReet Go to Table of Contents 9/49

Agent/Intermediary Name Agency/Intermediary Code Agent/Intermediary Contact details

#RakshakaranKiReet Go to Table of Contents 10/49

Accidental Total &

UIN 110A048V02 110A048V02

Details of Nominee (not applicable if Benefit Payout Option is Partner Care)

Details of Partner (applicable only if Benefit Payout Option is Partner Care)

#RakshakaranKiReet Go to Table of Contents 12/49

Beneﬁts you've opted for under the plan

Grace Period Waiting Period

Go to Table of Contents 13/49

Be Healthier, Happier, Everyday!

Know Your Health Improve Your Health

Take health checkups Improve it through physical

Online Assessments Maximum

Vitality Health Review 1,000

Vitality Nutrition Assessment 1,000

We look forward to a long and cherished relationship with you. ¬nn¬-Hrj¡¤WfqTi¬14-¬nn¬