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Proposal Form No.
šøÑzठ󡳢 >}.
KEYMAN QUESTIONNAIRE Part – 1
³åJ¸ ¤¸[v¡û¡¹ šøťऺã "}Å- 1
Name
Date of Birth
>à³
\@µ t¡à[¹J
1. Academic Qualifications [ÅÛ¡àKt¡
ì™àK¸t¡à
2. Please give details of occupation and state whether you are employed, self-employed, a shareholding director or in a partnership.
">åNøÒ A¡ì¹ ëšÅ๠[¤¤¹o šøƒà> A¡¹ç¡> &¤} "àš[> A¡ì³¢ [>™åv¡û¡, Ѭ-[>™åv¡û¡, ëÅÚà¹ìÒà[Á¡} l¡àÒüì¹C¡¹ "=¤à "}Åãƒà¹ l¡üìÀJ A¡¹ç¡>ú
3. Are any concurrent applications being made to other life Insurance Companies?
Yes / No, [if YES, please give details (indicating which life if joint life)]
">¸ ìA¡à> \ã¤> [¤³à ìA¡à´šà[>ìt¡ [A¡ &A¡Òü ÎìU "à줃> A¡¹à ÒìZá?
Ò¸òà / >à, ™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡> (\ìÚ@i¡ ºàÒüó¡ Òìº ìA¡à> \ã¤> l¡üìÀJ A¡¹ç¡>)
Company
Policy type and term
Sum insured
Reason for cover
ìA¡à´šà[>
š[º[ι ‹¹> &¤} ë³Úàƒ
[¤³àAõ¡t¡ "=¢¹à[Å
"àZáàƒì>¹ A¡à¹o
4. Please give details of existing policies for life, critical illness and income protection.
(Including which life if joint life):
">åNøÒ A¡ì¹ Òü[t¡³ì‹¸ [¤ƒ¸³à> \ã¤>, P¡¹ç¡t¡¹ ¤¸à[‹ &¤} "àÚ Îå¹Û¡à š[º[ÎP¡[º¹ [¤¤¹o šøƒà> A¡¹ç¡>ú
(\ìÚ@i¡ ºàÒüó¡ Òìº ìA¡à> \ã¤> ëÎÒü t¡=¸ ÎÒ) :
Company
Date effected
ìA¡à´šà[>
A¡à™¢A¡¹ Ò*Úà¹
t¡à[¹J
Policy type and term
Sum insured
Reason for cover
š[º[ι ‹¹> &¤} ë³Úàƒ
[¤³àAõ¡t¡ "=¢¹à[Å
"àZáàƒì>¹ A¡à¹o
Please also list any other companies which the life insured has been insured with during the last 5 years.
\ã¤> [¤³àAõ¡t¡ ¤¸[v¡û¡ Kt¡ ¤áì¹ ">¸ ë™ ÎA¡º ìA¡à´šà[> ë=ìA¡ [¤³à A¡[¹ìÚìá> ">åNøÒ A¡ì¹ ëÎP¡[º¹ t¡à[ºA¡à šøƒà> A¡¹ç¡>ú
5. Business details:
¤¸¤Î๠[¤¤¹o:
Name of company / partnership
ìA¡à´šà[>/"}Åãƒà[¹¹ >à³
Nature of business
¤¸¤Î๠šøAõ¡[t¡
When was the business established?
¤¸¤Îà[i¡ A¡ì¤ šø[t¡Ë¡à A¡¹à ÒìÚ[áº?
Number of employees
A¡³¢W¡à¹ã샹 Î}J¸à
6. What percentage of the company’s share capital does the life to be insured own? ________________% (Please attach a structure chart
showing all companies, partnerships or entities involved in the group, the ownership of each, and how they are related.)
ë™ ¤¸[v¡û¡¹ \ã¤> [¤³à A¡¹à Òì¤ [t¡[> ìA¡à´šà[>¹ A¡t¡ Åt¡à}Å ëÅÚ๠³èº‹ì>¹ ³à[ºA¡? (">åNøÒ A¡ì¹ &A¡[i¡ A¡àk¡àì³àKt¡ W¡ài¡¢ šøƒà>
A¡¹ç¡> &¤} ëÎ[i¡ìt¡ ƒìº ë™ ÎA¡º ìA¡à´šà[>, "}Åãƒà¹ "=¤à Ѭâ«à \ú[t¡ "àìá>, šøìt¡¸A¡[i¡¹ ³à[ºA¡à>à, &¤} ëÎP¡[º [A¡®¡àì¤ Î´š[A¢¡t¡
šøƒÅ¢> A¡¹ç¡>ú)
7. Please give details of the turnover, gross profit and net profit before tax for the last 3 years, and projected figures for the next financial
year: (please attach copies of Profit and Loss Account and Balance Sheets and IT Returns for last three years)
">åNøÒ A¡ì¹ Kt¡ 3 ¤áì¹¹ ëº>ìƒ>, A¡ì¹¹ šè줢 ì³ài¡ ºà®¡ * [>i¡ ºà®¡ &¤} š¹¤t¡¢ã "à[=¢A¡ ¤áì¹¹ šøàB¡º> š[¹Î}J¸à¹ [¤¤¹o šøƒà>
A¡¹ç¡> (">åNøÒ A¡ì¹ Kt¡ [t¡> ¤áì¹¹ ºà®¡ &¤} Û¡[t¡¹ [ÒÎठ&¤} ¤¸àìºX [Åi¡ &¤} "àÚA¡¹ [¹i¡àì>¢¹ A¡[š Î}™åv¡û¡ A¡¹ç¡>)
Year
Turnover
Gross profit
Net profit before tax
Net profit after tax
¤á¹
ëº>ìƒ>
ì³ài¡ ºà®¡
A¡ì¹¹ šè줢 [>i¡ ºà®¡
A¡¹ š¹¤t¡¢ã [>i¡ ºà®¡
8. Please give details of the life to be insured’s personal earnings as assessed for income tax for the last 2 year:
ë™ ¤¸[v¡û¡¹ \ã¤> [¤³à A¡¹à Òì¤ Kt¡ 2 ¤áì¹ "àÚA¡ì¹¹ \>¸ ³èº¸àÚ> ">å™àÚã t¡à¹ "àìÚ¹ [¤¤¹o šøƒà> A¡¹ç¡>
Particulars
[¤¤¹o
Salary or package
Dividends
ë¤t¡> "=¤à š¸àìA¡\
[l¡[®¡ìl¡“¡
Bonuses / commission
Share of profit
ì¤à>àÎ / A¡[³Å>
ºà쮡¹ "}Å
Other (please give details)
Total
ì³ài¡
">¸à>¸ (">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
Year
Year
¤á¹
¤á¹
9. Please estimate the value of your assets and business:
">åNøÒ A¡ì¹ "àš>๠δš[v¡ &¤} ¤¸¤Îà "à>å³à[>A¡ ³èº¸ l¡üìÀJ A¡¹ç¡>
Amount
Assets δš[v¡
š[¹³ào
Cash/ Deposits/ Certificates
Mortgage
Liabilities
Amount
ƒàÚ
"=¢¹à[Å
¤Þê¡A¡
>Kƒ/"à³à>t¡ /Îà[i¡¢[ó¡ìA¡i¡
Investments
Other personal loans
[¤[>ìÚàK
">¸ ¤¸[v¡û¡Kt¡ ˜¡o
NSC/ PPF/ UTI other savings
Personal notes
&>&Î[Î/ [š[š&ó¡ / Òül¡ü[i¡"àÒü ">¸à>¸
Îe¡Ú
¤¸[v¡û¡Kt¡ ì>ài¡
Residence/ House property
Other liabilities
¤àÎÑ‚à>/KõÒ Î´š[v¡
">¸à>¸ ƒàÚ
Vehicle(s)
Kà[Øl¡ (P¡[º)
Other (please specify)
">¸à>¸ (">åNøÒ A¡ì¹ l¡üìÀJ A¡¹ç¡>)
Total
ì³ài¡
Total
ì³ài¡
Net Worth:
[>i¡ ³èº¸:
(Assets- Liabilities)
(δš[v¡-ƒàÚ)
Please attach a list detailing personal and business assets at market value, together with copies of valuation certificates, if available.
">åNøÒ A¡ì¹ ¤à\๠³è캸 ¤¸[v¡û¡Kt¡ &¤} ¤¸¤Î๠δš[v¡¹ &A¡[i¡ t¡à[ºA¡à &¤} ëÎÒü ÎìU ™[ƒ =àìA¡ t¡àÒìº ³èº¸[>‹¢à¹o Å}Îàšy Î}™åv¡û¡
A¡¹ç¡>
10. Please give details of your dependants including their ages.
">åNøÒ A¡ì¹ "àš>๠l¡üš¹ [>®¢¡¹Å㺠¤¸[v¡û¡ìƒ¹ [¤¤¹o &¤} t¡à샹 ¤ÚÎ l¡üìÀJ A¡¹ç¡>ú
11. Is the life insured or the proposed policy owner currently bankrupt or a director of a company in receivership, or have they been so in the
pasts. YES / NO
(If Yes, please give details.)
\ã¤> [¤³àAõ¡t¡ ¤¸[v¡û¡ "=¤à šøÑzà[¤t¡ š[º[ι ³à[ºA¡ [A¡ ¤t¡¢³àì> ëƒl¡ü[ºÚà "=¤à ìA¡à´šà[>¹ ìA¡à> l¡àÒüì¹C¡¹ [A¡ [\´¶àƒà[¹ìt¡ "àìá>
"=¤à "t¡ãìt¡ A¡Jì>à [áìº>ú Ò¸òà / >à (™[ƒ Ò¸òà ÒÚ t¡àÒìº [¤¤¹o šøƒà> A¡¹ç¡>)
12. How long is the proposed policy expected to be in force?
Years
šøÑzà[¤t¡ š[º[Î A¡t¡ γìÚ¹ \>¸ A¡à™¢A¡¹ =àA¡à¹ šøt¡¸àÅà A¡¹à ÒìZá?
What is the source of premium payments? ( please tick)
ìA¡à> l¡ü;Î ë=ìA¡ [šø[³Úà³ šøƒà> A¡¹à Òì¤?(">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>)
¤á¹
Company ìA¡à´šà[>
Life insured
\ã¤> [¤³àAõ¡t¡
¤¸[v¡û¡
Borrowing (Please state source)
˜¡o NøÒo (">åNøÒ A¡ì¹ l¡ü;Î
l¡üìÀJ A¡¹ç¡>)
13. Is the intention to obtain a tax deduction for premiums? YES / NO
l¡üì„Ÿ [A¡ [šø[³Úàì³¹ \>¸ A¡ì¹ áàØl¡ šà*Úà? Ò¸òà / >à
_________________________________________________________________________________________________________________________
I declare 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 proposal.
"à[³ ìQàÈoà¡ 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 šøÑzà줹 ³èº¸àÚ> "=¤à KõÒãt¡ Ò*ÚàìA¡ šø®¡à[¤t¡ A¡¹ìt¡ šàì¹ú
I agree that this form will constitute part of my proposal (dated.............................) for life insurance and that failure to disclose any material fact known
to me may invalidate the contract between me and the Company.
"à[³ δ¶[t¡ šøƒà> A¡¹[á ë™ &Òü ó¡³¢ìA¡ "à³à¹ \ã¤> [¤³à¹ šøÑzà줹 (t¡à[¹J.............................) "}Å ¹ê¡ìš Ko¸ A¡¹à Òì¤ &¤}
"à³à¹ \à>à ìA¡à> P¡¹ç¡â«šèo¢ t¡=¸ šøA¡àÅ A¡¹ìt¡ "à[³ ¤¸=¢ Òìº ëÎi¡à "à³à¹ &¤} ëA¡à´šà[>¹ ³ì‹¸ Ò*Úà Wå¡[v¡û¡ìA¡ ¤à[t¡º A¡¹ìt¡ šàì¹ú
____________________________
____________________________
________________________________
___________________
Signature of the person to be insured
Date
ë™ ¤¸[v¡û¡¹ [¤³à A¡¹à Òì¤ t¡à¹ ѬàÛ¡¹
t¡à[¹J
_____________________________ ____________________________
Signature of witness
Name & Address of Witness
Îàۡ㹠ѬàÛ¡¹
ÎàÛ¡ã¹ >à³ &¤} [k¡A¡à>à
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]