NRI QUESTIONNAIRE

NRI QUESTIONNAIRE
Proposal Form No:
1. Full Name .......................................................................................................................................
Date of Birth:
D D M M Y Y
Y Y
2. Nationality ......................................................................................................................................
3. Country of permanent residence ...........................................................................................................................................................................................
...............................................................................................................................................................................................................................................
4. Date from which you became a permanent resident of country mentioned in (3)
5. Country of current residence (abroad) along with address
D D M M Y Y
Y Y
......................................................................................................................................................
...............................................................................................................................................................................................................................................
6. Date from which you became a permanent resident of country mentioned in (5)
D D M M Y Y
Y Y
7. Date of leaving India for the first time
D D M M Y Y
Y Y
8. Visa Status (if any)
9. Duration of stay abroad
10. Purpose of stay abroad
11. Are you gainfully employed abroad?
12. Your monthly income from employment (Scholarship/Assistantship for
students or trainees) in the foreign country
Please enclose original copies of the appointment letter, salary slip
& IT returns, including confirmation of
Scholarship/Assistantship
13. Passport No.
Date of issue:
D D M M Y Y
Y Y
Place of issue:
Attach a self-attested copy of your passport showing your name, date of birth & address, along with a self-attested copy of the Visa stamping
page of the passport, showing entry/exit/time period of stay in India.
14. Account number from which premium will be paid
15. Owner of account/if not self & relationship with owner
Type of account:
Resident account
NRO
NRE
FCNR
Bank Transfer/Draft
16. Repatriation benefit required?
(Only if type of account is NRE/FCNR)
17. Name & Address of a local person to whom the policy documents, premium notice etc. can be delivered
Name : .........................................................................................................................................................................................................................................
Address: .......................................................................................................................................................................................................................................
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 of acceptance of this proposal.
I fully understand that all the remittances under this proposal/policy shall be in Indian Rupee Currency and that currency fluctuation risks, if any, accruing
thereunder, shall be borne by me and that this proposal for insurance is subject to the jurisdiction of India and the laws prevailing in India.
I agree that this form will constitute part of my proposal for life insurance and that failure to disclose any material fact known to me may invalidate the
contract between the Company and me.
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A Joint Venture between Dabur Invest Corp. & Aviva Interna onal 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
qÁ§gï E£Éé¸ïÖ PÁ¥ïð ºÁUÀÆ C«ªÁ EAlgï£Áå±À£À¯ï ºÉÆðØAUïì °«ÄmÉqï £ÀqÀÄ«£À MAzÀÄ ¸ÀºÀAiÉÆÃUÀ
C«ªÁ fêÀ«ªÀiÁ PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï¡
PÉÃAzÀæ PÀbÉÃj: C«ªÁ UÉÆÃ¥ÀÄgÀ/lªÀgï, ¸ÉPÀÖgï gÀ¸ÉÛ, rJ¯ïJ¥sï UÉÆïïá ªÉÄÊzÁ£ÀzÀ JzÀÄgÀÄ, rJ¯ïJ¥sï WÀlÖ 5, ¸ÉPÀÖgï 43, UÀÄgïUÁAªï-122003. ºÀjAiÀiÁt,
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