Tata AIA Life Insurance Company Limited: Total & Permanent Disability Claim Form

Policy No.
Tata AIA Life Insurance Company Limited Claim No.:

(hereinafter called “Tata AIA” or “the Company”, whichever is applicable)
TOTAL & PERMANENT DISABILITY CLAIM FORM

Please affix recent passport
Office _______________________________ size photo of the Claimant
Agency ____________ Code ____________
Agent ____________ Code ____________
PART 1 (TO BE COMPLETED BY INSURED/CLAIMANT IN BLOCK LETTERS)
Please answer all questions, use “not applicable” (N/A) as appropriate instead of leaving it blank.
Counter-sign where amendments/ alterations are made in the form.
The filing of this claim form is not to be construed as an admission of liabilities of our Company.
No agent has been or is authorized to admit any liabilities on behalf of the Company.
Policy No.: Name of Insured: Age: D D M M Y Y This is a New Claim

I/D No: Further Claim
Sex: M F
Mailing Address: Contact Phone No.:
Pan Card No.
EMPLOYMENT PARTICULARS:
1. Occupation (if more than one, state all) and exact nature of 1.
occupational duties before disability
2. Name and address of business or employer 2.
3. Did you file a sick leave certificate with your employer? 3. Yes No
4. Date your last worked: 4. ______ DD ______ MM _________ YYYY
5. Date you returned to work. (If no, then give expected date of 4. ______ DD ______ MM _________ YYYY
return)
PLEASE COMPLETE IF DISABILITY WAS DUE TO ACCIDENT:

6a. Date , time and location of accident: 6a. ______ DD ______ MM _________ YYYY _____am/pm
at _________ city
b. Where and how did it happen? 6b.
c. Part of body injured and type of injury. 6c
PLEASE COMPLETE IF DISABILITY WAS DUE TO ILLNESS:
7a. Indicate the illness and give a brief description of symptoms. 7a.
Registered and Corporate Office : Tata AIA Life Insurance Company Ltd. (IRDA Reg. No. 110),14th Floor, Tower A,
Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013. CIN: U66010MH2000PLC128403
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.
Visit us at www.tataaia.com or call our helpline no.1860 266 9966 (local charges apply) or email us at
[email protected] or SMS “LIFE” to 58888
L&C/Misc/2017/Dec/475
b. How long had he/she been having these symptoms 7b.
c. Give details of consultation. 7c. Date Name(s) and Address(es) of Doctor(s)/Hospital(s)
i) The doctor first consulted for this illness. i)

ii) The doctor who referred the insured to hospital. ii)
iii) Doctors seen for any similar condition in the past. iii)
8. DETAILS OF PHYCICIAN(S) CONSULTED OR HOSPITAL(S) ADMITTED FOR CURRENT DISABILITY
Name(s) Address(es) Admission/Patient No. (s) Admission Date(s)
a)
b)
c)
9. ARE YOU CURRENTLY INSURED FOR DISABILITY BENEFIT WITH ANY OTHER INSURANCE COMPANY OR INSTITUTION
(If “YES”, please provide following information)
Name of Insurer Company/Institution Amount of Life Insurance Rider Attached Policy Number
a)
b)
c)
DECLARATION AND AUTHORIZATION
I declare that the answers given are true and complete.
I/We hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise
obtained) is provided and may be held, used, and disclosed by the company to individuals/organizations associated with the Company or any
selected third party (within or outside of India, including reinsurance and claims investigation companies and industry associations/federations) for
the purposes of processing this application and providing subsequent services for this and other financial products and services, direct marketing,
and data matching, and to communicate with me/us for such purposes. I/We understand that the Company may be unable to process this
application if I/We fail to provide any information requested in this application.
I hereby irrevocably authorize:
a. any organization, institution, or individual that has any record or knowledge of my/the Insured’s health and medical history or any
treatment or advice and that has been or may hereafter be consulted, other personal information or details of related accident/injury to
disclose to the Company such information. This authorization shall bind my/the Insured’s successors and assigns and remain valid
notwithstanding my/the Insured’s heath or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as
the original.
b. the Company or any of its approved medical examiners or laboratories to perform the necessary medical assessment and tests to
underwrite and evaluate my/the Insured’s health status in relation to this application and any claim arising therefrom. These tests may
include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, acquired immunodeficiency
syndrome (AIDS), infection by any human immunodeficiency virus (HIV), immune disorder or the presence of medications, drugs, nicotine
or their metabolites.
_____________________________________ _________________________________
Witness Signature of Insured (see Remark)
Date :
Remark: This declaration and authorization must be signed by the Insured. If the Insured is a minor, the Insured’s parent/legal guardian can sign
on his/her behalf.
Please complete if the signature is not given by the Insured.
Name (in block letter) _______________________________ Relationship with Insured :_____________________
Registered and Corporate Office : Tata AIA Life Insurance Company Ltd. (IRDA Reg. No. 110),14th Floor, Tower A,
Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013. CIN: U66010MH2000PLC128403
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.
Visit us at www.tataaia.com or call our helpline no.1860 266 9966 (local charges apply) or email us at
[email protected] or SMS “LIFE” to 58888
L&C/Misc/2017/Dec/475

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Policy No.

Tata AIA Life Insurance Company Limited Claim No.:

TOTAL & PERMANENT DISABILITY CLAIM FORM

Policy No.: Name of Insured: Age: D D M M Y Y This is a New Claim

Mailing Address: Contact Phone No.:

Pan Card No.

2. Name and address of business or employer 2.

4. Date your last worked: 4. ______ DD ______ MM _________ YYYY

PLEASE COMPLETE IF DISABILITY WAS DUE TO ACCIDENT:

b. Where and how did it happen? 6b.

c. Part of body injured and type of injury. 6c

PLEASE COMPLETE IF DISABILITY WAS DUE TO ILLNESS:

c. Give details of consultation. 7c. Date Name(s) and Address(es) of Doctor(s)/Hospital(s)

i) The doctor first consulted for this illness. i)

8. DETAILS OF PHYCICIAN(S) CONSULTED OR HOSPITAL(S) ADMITTED FOR CURRENT DISABILITY

Name(s) Address(es) Admission/Patient No. (s) Admission Date(s)

DECLARATION AND AUTHORIZATION

I declare that the answers given are true and complete.

I hereby irrevocably authorize:

Please complete if the signature is not given by the Insured.

Name (in block letter) _______________________________ Relationship with Insured :_____________________

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4. Date your last worked: 4. DD MM _____ YYYY

Name (in block letter) ___________ Relationship with Insured :_