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Proposal Form No.
¥Àæ¸ÁÛªÀ£Á Cfð ¸ÀASÉå:
POLICE OR PARAMILITARY AND ARMED FORCES QUESTIONNAIRE
¥ÉÆ°¸ï CxÀªÁ CgÉ ¸ÉãÁ¥ÀqÉ ºÁUÀÆ ¸À±À¸ÀÛç ¸ÉãÁzÀ¼À ¥Àæ±ÁߪÀ½
The statement should be completed by the person to be insured:
«ªÉÄ ªÀiÁr¹PÉƼÀî¨ÉÃPÁzÀªÀgÀÄ F ºÉýPÉAiÀÄ£ÀÄß ¸ÀA¥ÀÆtðUÉƽ¸À¨ÉÃPÀÄ
Full Name
Date of Birth
¥ÀÆwð ºÉ¸ÀgÀÄ
d£Àä ¢£ÁAPÀ:
1.
Which Branch of Police/Para Military or Armed forces are you serving? ¤ÃªÀÅ ¥ÉÆ°¸ï/CgÉ ¸ÉãÁ¥ÀqÉ E®èªÉà ¸À±À¸ÀÛç ¸ÉãÁ¥ÀqÉAiÀÄ AiÀiÁªÀ ±ÁSÉAiÀÄ°è ¸ÉÃªÉ ¸À°è¸ÀÄwÛgÀÄ«j?
2.
What is your rank? ¤ªÀÄä ¸ÁÜ£À K£ÀÄ?
3.
Current place of posting (Please give details)
4.
What are your present duties? ¤ªÀÄä
¥Àæ¸ÀÄÛvÀ PÁAiÀÄ𠤪Àð»¸ÀÄwgÀĪÀ ¸ÁÜ£À (zÀAiÀÄ«lÄÖ «ªÀgÀUÀ¼À£ÀÄß ¤Ãr)
FV£À PÀvÀðªÀåUÀ¼ÉãÀÄ?
Please indicate if you are involved or likely to be involved in any of the following activities mentioned below.
(a) Weapons Handling
(b) Explosives (Bomb Disposal)
(c) Underwater Diving
(d) Aviation
(e) Paratrooper
(f)
Special services
(g) Overseas peace keeping mission (UN mission)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
(h)
Yes
No
Others
zÀAiÀÄ«lÄÖ F PɼÀV£À ZÀlĪÀnPÉUÀ¼À°è ¨sÁVAiÀiÁVgÀÄ«gÉà CxÀªÁ ¨sÁVAiÀiÁUÀĪÀ ¸ÁzsÀåvÉUÀ½ªÉAiÉÄà J£ÀÄߪÀÅzÀ£ÀÄß ¸ÀÆa¹
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
±À¸ÀÛçUÀ¼À ¤ªÀðºÀuÉ
¸ÉÆáÃlPÀUÀ¼ÀÄ (¨ÁA¨ï ¤¶ÌçAiÀÄUÉƽ¸ÀÄ«PÉ)
¤ÃgÉƼÀV£À qÉÊ«AUï
ªÁAiÀÄÄAiÀiÁ£À
¥ÁgÁlÆæ¥Àgï
«±ÉõÀ ¸ÉêÉUÀ¼ÀÄ
¸ÁUÀgÁzÁZÉV£À ±ÁAw ¸ÁÜ¥À£Á UÀÄj (AiÀÄÄ J£ï «Ä±À£ï)
EvÀgÉ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
ºËzÀÄ
C®è
C®è
C®è
C®è
C®è
C®è
C®è
C®è
If you have answered yes to any of the above questions, please provide full details.
¤ÃªÀÅ ªÉÄð£À AiÀiÁªÀÅzÉà ¥Àæ±ÉßUÀ½UÉ ºËzÀÄ JAzÀÄ GvÀÛj¹zÀ°è, zÀAiÀÄ«lÄÖ ¸ÀA¥ÀÆt𠫪ÀgÀUÀ¼À£ÀÄß MzÀV¹
5. Are you likely to be posted in any of the troubled areas like J&K, Assam etc? If yes, please furnish the necessary details.
F CfðAiÀÄÄ £À£Àß fêÀ«ªÉÄ ¥Àæ¸ÁÛªÀ£ÉAiÀÄ ¨sÁUÀªÁV gÀÆ¥ÀÄUÉƼÀÄîvÀÛzÉ (¢£ÁAPÀ. . . . . .) ªÀÄvÀÄÛ £À¤ßAzÀ AiÀiÁªÀÅzÉà ªÀ¸ÀÄÛ«µÀAiÀĪÀÅ ªÀÄÄaÑqÀ®ànÖzÀÝgÉ £À£Àß ªÀÄvÀÄÛ PÀA¥À¤AiÀÄ
ªÀÄzsÀåzÀ F M¥ÀàAzÀªÀÅ C¥ÀªÀiË®åUÉƼÀÄîvÀÛzÉAiÉÄAzÀÄ £Á£ÀÄ M¥ÀÄàvÉÛãÉ.
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 the proposal.
ªÉÄÃ¯É ¤ÃrzÀAxÀ GvÀÛgÀUÀ¼ÀÄ ¸ÀvÀåªÁVªÉ, £À£Àß Cj«£ÉÆA¢UÉ ¤ÃrgÀĪÀÅzÁVªÉ ªÀÄvÀÄÛ F ¥ÀÛ¸ÁÛªÀ£ÉAiÀÄ ªÀiË®å¤zsÁðgÀPÉÌ CxÀªÁ M¦àUÉUÉ ¥ÀjuÁªÀĪÀÅAlÄ ªÀiÁqÀĪÀAxÁ AiÀiÁªÀÅzÉÃ
ªÀ¸ÀÄÛ CxÀªÁ «µÀAiÀĪÀ£ÀÄß £Á£ÀÄ ªÀÄÄaÑnÖ®èªÉAzÀÄ WÉÆö¸ÀÄvÉÛãÉ.
I agree this form will constute part of my proposal for life insurance and that failure to disclose any material fact known to me may
invalidate the contract between me and Company.
F CfðAiÀÄÄ £À£Àß fêÀ«ªÉÄ ¥Àæ¸ÁÛªÀ£ÉAiÀÄ ¨sÁUÀªÁV gÀÆ¥ÀÄUÉƼÀÄîvÀÛzÉ (¢£ÁAPÀ. . . . . .) ªÀÄvÀÄÛ £À¤ßAzÀ AiÀiÁªÀÅzÉà ªÀ¸ÀÄÛ«µÀAiÀĪÀÅ ªÀÄÄaÑqÀ®ànÖzÀÝgÉ £À£Àß ªÀÄvÀÄÛ PÀA¥À¤AiÀÄ ªÀÄzsÀåzÀ
F M¥ÀàAzÀªÀÅ C¥ÀªÀiË®åUÉƼÀÄîvÀÛzÉAiÉÄAzÀÄ £Á£ÀÄ M¥ÀÄàvÉÛãÉ.
Signature of the life to be insured
Date
«ªÉÄ ªÀiÁr¹PÉƼÀÄîªÀªÀgÀ ¸À»:
¢£ÁAPÀ:
Signature of witness
¸ÁQëAiÀÄ ¸À»
Name and Address of Witness
¸ÁQëAiÀÄ ºÉ¸ÀgÀÄ, «¼Á¸À ªÀÄvÀÄÛ GzÉÆåÃUÀ
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, ¨sÁgÀvÀ
£ÉÆÃAzÁ¬ÄvÀ PÀbÉÃj: 2£Éà ªÀĺÀr, ¥ÀæPÁ±ï¢Ã¥ï PÀlÖqÀ, 7 mÁ¯ï¸ÁÖAiÀiï gÀ¸ÉÛ, £ÀªÀ zɺÀ° - 110001, ¨sÁgÀvÀ
Tel/ zÀÆgÀªÁtÂ: +91 (o) 124 270 9000 Fax/ ¥sÁåPïì: +91 (0) 124 257 1210.
www.avivaindia.com Email/ E-ªÉÄïï :[email protected]
UW /Non-Med
Q/Ver 1.0/1st
April 2011