Sailing Questionnaire šàºìt¡àºà ì>ïW¡àº>à šøťऺã

Sailing Questionnaire šàºìt¡àºà ì>ïW¡àº>à šøťऺã
Last Name: ___________________________________ First Name: __________________________________
šƒ[¤:
Please Print ">åNøÒ A¡ì¹ [šø@i¡ A¡¹ç¡>
šø=³ >à³:
Date of Birth:___________________________________ Policy/Application Number: ______________________
¶\@µ t¡à[¹J:
š[º[Î/"à줃>šìy¹ >´¬¹:
1.
2.
What type/s of craft do you sail (please include size)?
"àš[> ìA¡à> ‹¹>/P¡[º¹ ì>ïA¡à W¡àºà> (">åNøÒ A¡ì¹ "àA¡à¹
l¡üìÀJ A¡¹ç¡>)?
Please state the nature of your sailing:
">åNøÒ A¡ì¹ "àš>๠šàºìt¡àºà ì>ïW¡àº>๠‹¹o l¡üìÀJ A¡¹ç¡> :
 Recreational
[¤ì>àƒ> ³èºA¡
3.
 Competitive
šø[t¡ì™à[Kt¡à ³èºA¡
 Sponsored
 Amateur
šõË¡ìšàÈA¡t¡à šøàœ¡
 Professional
"ìšÅàƒà¹
ëšÅàƒà¹
When did you first start sailing?
"àš[> šø=³ A¡ì¤ šàºìt¡àºà ì>ïW¡àº>à Ç¡¹ç¡ A¡ì¹>?
4.
Where do you sail?
"àš[> ìA¡à=àÚ šàºìt¡àºà ì>ïW¡àº>à A¡ì¹>?
5.
Please advise the number of crew (including yourself)?
">åNøÒ A¡ì¹ >à[¤A¡ƒìº¹ ΃θ Î}J¸à ("àš>àìA¡ "”z®å¢¡v¡û¡ A¡ì¹) l¡üìÀJ A¡¹ç¡>?
6.
7.
Please provide details of your sailing qualifications/certifications:
">åNøÒ A¡ì¹ "àš>๠šàºìt¡àºà ì>ïW¡àº>๠ì™àK¸t¡à/Îà[i¡¢[ó¡ìA¡Å>-&¹
[¤¤¹o šøƒà> A¡¹ç¡> :
Qualification
When obtained
ì™àK¸t¡à
A¡ì¤ "\¢> A¡ì¹ìá>
Are you a member of a sailing club or association?
"àš[> [A¡ ìA¡à> ëÎÒü[º} Aáठ"=¤à Î[³[t¡¹ ΃θ?
If yes, please provide details:
™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡> :
 Yes
Ò¸òà
 No
>à
8.
Do you participate, or do you have any plans to participate, in any offshore
racing events?
"àš[> [A¡ ìA¡à> l¡üšA衺¤t¡¢ã ë¹[Î} šø[t¡ì™à[Kt¡àÚ "}ÅNøÒo A¡ì¹> ¤à A¡¹à¹ ìA¡à>
š[¹A¡¿>à "àìá?
 Yes
 No
Ò¸òà
>à
If yes, please provide details:
™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡> :
9.
Name of event
Category
Date
šø[t¡ì™à[Kt¡à¹ >à³
ëÅøoã
t¡à[¹J
Please provide any additional information that you feel is important:
"à>åÈ[UA¡ ìA¡à> t¡=¸ "àš>๠™[ƒ P¡¹ç¡â«šèo¢ ¤ìº ³ì> ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ ëÎP¡[º šøƒà> A¡¹ç¡> :
Declaration ìQàÈoà
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.
"à[³ [>[ÆW¡t¡ A¡¹[á ë™ "à[³ ë™ l¡üv¡¹P¡[º [ƒìÚ[á ëÎP¡[º "à[³ ™t¡ƒè¹ \à[>, Ît¡¸ &¤} "à[³ &³> ìA¡à> P¡¹ç¡â«šèo¢
t¡=¸ ìKàš> A¡[¹[> ™à &Òü "à줃ì>¹ ³èº¸àÚ> "=¤à KõÒãt¡ Ò*ÚàìA¡ šø®¡à[¤t¡ A¡¹ìt¡ šàì¹ú
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).
"à[³ &Òü ³ì³¢ δ¶[t¡ šøƒà> A¡¹[á ë™ &Òü ó¡³¢ "à³à¹ [¤³à(P¡[º)-¹ \>¸ "à줃ì>¹ "}Å ¹ê¡ìš [¤ì¤[W¡t¡ Òì¤ &¤}
"à[³ "à³à¹ \à>à ìA¡à> P¡¹ç¡â«šèo¢ t¡=¸ [ƒìt¡ ¤¸=¢ Òìº "à³à¹ [¤³à (P¡[º) ¤à[t¡º ÒìÚ ë™ìt¡ šàì¹ú
/

Name
>à³
Signature
/
Date
ѬàÛ¡¹
t¡à[¹J
A Joint Venture between Dabur Invest Corp. & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
l¡à¤¹ Òü>쮡С A¡š¢ &¤} "[®¡®¡à Òü@i¡à¹>¸àÅ>ຠëÒà[Á¡}Î [º[³ìi¡ìl¡¹ &A¡[i¡ ì™ï= l¡ü샸àK
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡
ëÒl "[ó¡Î: "[®¡®¡à i¡à*Úà¹, ëÎC¡¹ ì¹àl¡, [l¡&º&ó¡ Kºó¡ ìA¡àì΢¹ [¤š¹ãìt¡, [l¡&º&ó¡ ëó¡\ V, ëÎC¡¹ 43, P¡¹Kòà*-122003ú Ò[¹Úà>à Òü[“¡Úàú
[>¤[Þê¡t¡ A¡à™¢àºÚ 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢, [>l¡ü [ƒ[À-110001ú Òü[“¡Úà
Tel/ ëi¡[ºìó¡à>:+91 (0) 124 270 9000 Fax/ ó¡¸àG: +91 (0) 124 257 1210.
www.avivaindia.com Email/ Òü쳺 :[email protected]
Uw /Non-Med Q/Ver 1.0/1st April 2011