,



,
MU01 C230378803 SP 401/1719 BROK Term_EIA C-150
November 22, 2021
AKSHAY MOGHE
V N RAO HOUSE
BEHIND OLD NOVA OFFICE WARD NO-03 H,NO-1355,
MAHAMAYA VIHAR WARE HOUSE ROAD
LANE R2
BILASPUR 495001
CHHATTISGARH INDIA
M- 9527071900

TATA AIA LIFE SAMPOORNA RAKSHA SUPREME

Non-Linked, Non-Participating Individual Life Insurance Plan
1. Part A

Dear AKSHAY MOGHE,

Thank You for choosing Us for Your insurance needs. Tata AIA Life Insurance Company Limited is committed to give
You world-class products and professional service.

We take great pleasure in presenting Your Policy document. Please check Your personal details and the Policy provisions
carefully. Should You have any queries, please contact Your agent/intermediary or contact Us at the address mentioned
below. You can also reach Us via email at customercare@tataaia.com or call Our helpline number 1860-266-9966 (Local
charges apply).
Agent/Intermediary Name: NJ Insurance Brokers Pvt Ltd
Agency/Intermediary Code/License: 004503118
Agent/Intermediary Contact details: 3985500 / khozema@njgroup.in
In order to provide better services, We request You to intimate Us in the event of any change in the address of the
Policyholder or the Nominee.

You have a free look period of 30 days from the date of receipt of the policy document, to review the terms and
conditions of the Policy. If You disagree to any of these terms or conditions, You have the option to return the Policy
for cancellation, stating the reasons for objection and be entitled to a refund of the premiums paid without interest after
deduction of proportionate risk premium, stamp duty and medical examination cost along with applicable taxes, if any.
If You notice any error on examination of the Policy, please return the Policy to the Company immediately for
correction.

At Tata AIA Life Insurance Company Limited, We believe that life inspires Us to think ahead. Our insurance solutions
are therefore designed to be a step ahead, thus giving You an advantage to adapt to tomorrow’s changes, starting today.

We look forward to a long and cherished relationship with You.

Best wishes,
For and on behalf of
Tata AIA Life Insurance Company Limited

Naveen Tahilyani
CEO & Managing Director
Authorised Signatory

Policy Servicing Branch : 1st Flr,Simran Cntr,30/H Parsi, Panchayat Mrg,Andheri-E,Mumbai - 400093
Tata AIA Life Insurance Company Ltd (IRDA of India Regn.No.110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
"Stamp duty of Rs. 2000 is paid as provided under Article 47(C)/(D) of Indian Stamp Act, 1899 and included in
Consolidated Stamp duty paid to the Government of Maharashtra Treasury vide order of Addl. Controller of Stamps,
Mumbai at General Stamp office, Fort, Mumbai – 400001 vide his order No. LOA/CSD/163/2021/4392 / Date
25/10/2021 / Validity period Dt. 26/10/2021 to Dt. 31/10/2022"

(Signature)
Proper Officer

TATA AIA LIFE SAMPOORNA RAKSHA SUPREME, Non-Linked, Non-Participating Individual

Life Insurance Plan

LIFE INSURED AKSHAY MOGHE

POLICY NUMBER C230378803

PREAMBLE

Tata AIA Life Insurance Company Limited (“the Company”) having received a Proposal Form and other related
documents with Declaration thereto and initial Premium from the Policyholder hereby issues Tata AIA Life Sampoorna
Raksha Supreme, a Non-Linked, Non-Participating Individual Life Insurance Plan. The basic insurance plan, coverage,
Premium and benefits provided under this Policy, are specified in the Policy Schedule.

We agree to pay the benefits under this Policy on the happening of the insured event, while this Policy is in force subject
to the terms and conditions stated herein.

Signature valid
Signed by: Naveen Tahilyani
Date:
Location:

Registrar Managing Director and CEO

This is a system generated document requiring no physical signature.

 POLICY SCHEDULE
Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02)
Non-Linked, Non-Participating Individual Life Insurance Plan
THIS SCHEDULE MUST BE READ WITH THE POLICY DOCUMENT AND IS PART OF THE LIFE INSURANCE CONTRACT

Policyholder Details Policyholder/ Life Assured (First Life) Life Assured (Second Life)
Name AKSHAY MOGHE N/A
Address V N RAO HOUSE
N/A
BEHIND OLD NOVA OFFICE WARD NO-03
N/A
H,NO-1355,
N/A
MAHAMAYA VIHAR WARE HOUSE ROAD
N/A
LANE R2
N/A
BILASPUR
N/A
CHHATTISGARH
N/A
495001
Client ID 311557040 N/A
Date of Birth 08/10/1987 N/A
Age at entry 33 years N/A
Age Admitted Y N/A
Gender MALE N/A

Policy Details
Policy Number : C230378803 Mode of Premium Payment : Annual
Plan Option : Life Annualised Premium (Excl. taxes) Rs : 13,200.00
Date of Commencement of Policy : 07/10/2021 Premium (Excl. taxes) Rs. 13,200.00
Date of Commencement of Risk : 07/10/2021 Applicable taxes, cessess and levies Rs. : 2,376.00
Date of Maturity of Policy : 07/10/2059 Total Modal Premium (Incl. taxes) Rs. : 15,576.00
Premium Due Date (s) : 07/10/2022 Top-Up : N/A
Policy Term : 38 years Top-Up Rate : N/A
Premium Paying Term : 38 years Mode of Premium Payment on Top-up : N/A
Life stage Option : No
Income Start Age : N/A
Income Rate : N/A
Credit Interest Rate : N/A

Base Plan/Rider Name Basic Sum Assured Modal Premium Date of Due Date of Policy Premium
(Rs.) (Incl. taxes) Maturity of Last Premium Term(Years) Payment
(Rs.) Policy Payment Term (Years)
Tata AIA Life Insurance
Sampoorna Raksha Supreme 1,00,00,000.00 15,576.00 07/10/2059 07/10/2058 38 38
(UIN: 110N160V02)

Benefit Payable:
As per the Clause 3.1 of Part C and Plan Option chosen

Nominee details (under section 39 of the Insurance Act 1938)

Name of the Nominee (s) Relationship with Life Assured Gender Age Nomination %
ABOLI MOGHE Spouse Female 34 100.00

Appointee Details (Applicable in case the Nominee is a minor)

Name of the Appointee (s) Relationship with nominee Gender Age
NA NA 0

On examination of the Policy, if you notice any mistake, please return the Policy to the Company immediately for correction.

Tata AIA Life Insurance Company Ltd (IRDA of India Regn.No.110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
 You are the
Rakshakaran Hero.

Dear AKSHAY MOGHE,

You are now the proud owner of a Tata AIA Life Insurance Sampoorna Raksha
Supreme. (Policy number C230378803)
We at Tata AIA Life Insurance have embarked on an initiative – Rakshakaran Hero –
through which we will plant a sapling for every Term plan that we sell. We will do this
on your behalf, thereby ensuring that you safeguard your family’s financial future and
also secure the world.
Your decision to secure your family is truly commendable in more ways than one.
You secured your family’s financial future and have also helped protect the world.
Your sapling is geo-tagged with a unique number 3072032
You can log on to https://www.grow-trees.com/locatetree.php.
Enter your unique number to view the location of your sapling.
Congratulations on becoming a Rakshakaran Hero and making the world a
greener and better place.

Naveen Tahilyani
Managing Director & Chief Executive Officer
Tata AIA Life Insurance

For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale. Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) CIN:
U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. 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. For any information including cancellation, claims and complaints, please contact
our Insurance Advisor / Intermediary or visit Tata AIA Life’s nearest branch office or call 1-860-266-9966 (local charges apply) or write to us at customercare@tataaia.com. Visit us at:
www.tataaia.com or SMS 'LIFE’ to 58888. Ÿ UIN:110N129V03 Ÿ L&C/Misc/2019/Sep/351
BEWARE OF SPURIOUS/ IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to
FRAUD PHONE CALLS! lodge a police complaint.
Certificate Number: 3072032

Presented to

AKSHAY MOGHE
Policy Number: C230378803
Project Name : Trees for Himalayan Biodiversity,Nainital,Uttarakhand,India
A token of appreciation for securing your family’s financial
cial future
cia
and protecting the world, one tree at a time.

Naveen Tahilyani
Managing Director & Chief Executive Officer, Tata AIA Life Insurance

Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No. 110). CIN: U66010MH2000PLC128403.
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
OTHER ENDORSEMENT
 Tata AIA Life Insurance Sampoorna Raksha Supreme

2 PART B “Policy Schedule” means the policy schedule and any endorsements
attached to and forming part of the Policy and if any updated Schedule is
Tata AIA Life New Term Insurance Plan is an Non-linked,
issued, then, the Schedule latest in time;
Non-participating Individual Life Insurance Plan.
“Policy Year” means a period of 12 (Twelve) months commencing from
2.1. Basic definitions the Date of Commencement of Policy and every Policy Anniversary
“Age” means age as on the last birthday; i.e. the age of the Life Insured in thereafter;
completed years as on Date of Commencement of Policy and is as shown “Premium” means the amount specified in the Policy Schedule, payable
in the Policy Schedule; by you, by the due dates to secure the benefits under the Policy, excluding
“Annualised Premium” shall be the Premium payable in a Policy Year applicable tax, Rider Premiums, Extra Premiums, if any;
under a non-Single Pay option chosen by the Policyholder, excluding “Proposal Form” means the form filled in and completed by You for the
taxes, Rider Premiums, Extra Premiums and loading for Modal Premiums, purpose of obtaining insurance coverage under the Policy;
if any; as specified in the Policy Schedule;
“Reduced Paid-up Policy” mean a Policy which has acquired Surrender
“Basic Sum Assured/Base SA” is as mentioned in the Policy Schedule; Value under Life Plus or Life Income Plan Option and subsequent Premium
“Claimant” means the person entitled to receive the Policy benefits and remains unpaid at the end of Grace Period;
includes the Policyholder, surviving Life Insured, the Nominee, the “Revival Period” means a period of 5 (five) years from the due date of the
assignee, the legal heir, the legal representative(s) or the holder(s) of first unpaid Premium;
succession certificate as the case may be;
“Single Premium” shall be the Premium payable under a Single Pay
“Date of Maturity of Policy” means the date specified in the Policy option as chosen by the Policyholder at the inception of the Policy,
Schedule on which the Policy Term expires; excluding the applicable taxes Rider Premiums, Extra Premiums, if any;
“Extra Premium” means an additional amount charged by Us, as per Our “Special Surrender Value” means the Special Surrender Value under Life
Underwriting Policy, which is determined on the basis of disclosures made Plus and Life Income Plan Option computed in accordance with Clause
by You in the Proposal Form or any other information received by Us 4.2.1 of Part D;
including medical examination report of the Life Insured;
"Special Surrender Value Factors” are factors determined to compute
“Grace Period” means a period of 15 (Fifteen) days from the due date of the Special Surrender Value, which can be revised by Us on the basis of
the unpaid Premium for monthly Premium payment mode and 30 (Thirty) Our experience from time to time as per the provisions of Clause 4.2.1
days from the due date of unpaid Premium for all other Premium payment ‘Surrender Benefit’ under Part C;
mode, except Single Pay;
“Surrender Value” means an amount payable on Surrender of this Policy,
“Guaranteed Surrender Value” shall be the minimum Surrender Value which will be the higher of the Guaranteed Surrender Value or the Special
under Life Plus and Life Income Plan Option computed in accordance with Surrender Value.;
Clause 4.2.1 of Part D, which is guaranteed by Us. The Guaranteed
Surrender Value will be determined in the Policy Year in which the “Total Premiums Paid" means total of all the premiums received,
Surrender is effected; excluding any Extra Premiums, any rider premiums and taxes,;
“IRDAI/Authority” means the Insurance Regulatory and Development “Underwriting Policy” means our then prevailing Underwriting Policy as
Authority of India; approved by Our board of directors;
“Lapsed Policy” means a Policy where the due Premium has not been “Waiting Period” means a period of first 90 days from the Date of
received till the expiry of the Grace Period and if Life Plus or Life Income Commencement of Risk;
option has been chosen, at least 2 (two) full years’ Premiums have not “We”, “Us”, “Our” or “Company” refers to Tata AIA Life Insurance
been paid (except in case of Single Pay Policy); Company Limited; and
“Life Insured/Assured” means the person whose life is insured or “You” or “Your” means the Policyholder of this Policy.
assured under the Policy and is shown in the Policy Schedule; Whenever the context requires, the masculine form shall apply to feminine
“Medical Practitioner” means a person who holds a valid registration and singular terms shall include the plural.
from the Medical Council of any State or Medical Council of India or
Council for Indian Medicine or for Homeopathy set up by the Government 3. PART C
of India or a State Government and is thereby entitled to practice medicine 3.1. Benefits
within its jurisdiction; and is acting within its scope and jurisdiction of
license. This would mean a practitioner treating the Life Insured must be The benefits shall depend on the Plan Option and Sum Assured Option (if
holding a degree equivalent to MD/MS or higher in the relevant field to any) chosen by You at the inception of the Policy and cannot be changed
certify the medical condition. The Medical practitioner should not be: once chosen.
• the Policyholder/Life Insured himself/herself; or Sum Assured Options: (A. Available only under Life and Life Plus options.
• An authorized insurance intermediary (or related persons) * involved B. Not applicable if the Policy is availed under Point of Sale product norms)
with selling or servicing the insurance contract in question; or I. Life Stage:
• Employed by or under contractual engagement with the Company; or If you have chosen Life Stage Plan Option at the inception of the
• Related to the Policyholder/Life Insured by blood or marriage. Policy, You may increase the Base SA on happening of any one of the
*“Related Persons” refers to individuals related to the insurance intermediary by blood following events, subject to Underwriting Policy and the option to
or by marriage who are practicing as Medical Practitioners; increase the Base SA is exercised within 180 days of the
“Nominee” means the person named in the Policy Schedule who has happening/incidence of the following event(s):
been nominated by You in accordance with Section 39 of the Insurance
Act, 1938 as amended from time to time to receive benefits in respect of Event Additional Sum Assured
this Policy; as % of Base SA

“Paid-up Policy” means a Policy wherein all the due Premiums have been Marriage (One Marriage Only) 50%
received by the Company; Birth/Adoption of 1st Child 25%
“Policy” means the contract of insurance entered into between You and Birth/Adoption of 2nd Child 25%
Us as evidenced by this document, the Proposal Form, the Policy Schedule
and any additional information/document(s) provided to Us in respect of Home Loan disbursal* 100%, subject to home loan
the Proposal Form along with any written instructions from You subject to amount sanctioned
Our acceptance of the same and any endorsement issued by Us; *Subject to Underwriting Policy.
“Policy Anniversary” refers to the annual anniversary of the Date of The Additional Sum Assured can only be taken in the form of (up to) 4
Commencement of Policy;
tranches as mentioned in the above table provided no prior claim

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 payment has been made under Payor Accelerator Benefit, where We
Benefit Option Age
will charge additional Premium for each tranche of the Additional Sum
Assured. The Premium amount for the original Base SA remains Life 65
unaltered. Any increase in the Base SA shall be effective from the Life Plus 65
Policy Anniversary succeeding the option exercise date.
After the payment of Premiums for first 5 (five) completed Policy Years, - Outstanding Policy Term as of the Policy Anniversary following the
You may opt to surrender the Additional Sum Assured tranches at date of opting for Additional Sum Assured, subject to the minimum
once or successively. The tranches shall be terminated after payment Policy Term.
of any applicable value on surrender. The tranches will be surrendered - Outstanding Premium Paying Term as of the Policy Anniversary
in reverse order to which they were availed, i.e. the latest tranche will
following the date of opting for Additional Sum Assured, subject to a
be surrendered first, followed by the penultimate tranche, and so on.
minimum Premium Paying Term of 13 months.
This shall be allowed till all incremental tranches are removed. Once
reduced, the Premium or sum assured cannot be subsequently - Aggregate sum assured (including the requested Additional Sum
increased. The Policy shall continue with the Effective Sum Assured Assured) under the Policy.
(as defined under Clause 3.1.2 ‘Death Benefit’ of Part C), as applicable
- Underwriting Policy of the Company.
at the time of termination of the tranche(s), for rest of the Policy Term.
II. Top-Up Sum Assured: 3.1.1. Maturity Benefit
Where the Premium Payment Term is at least 5 years, You can opt to 3.1.1.1. Life/Life Income/Credit Protect Option (as chosen)– No
exercise the Top-SA option at the time of purchase of the Policy benefit shall be payable.
subject to Underwriting Policy. Under this option, the life cover shall
increase, at every Policy Anniversary, by a fixed percentage of 5% of 3.1.1.2. Life Plus Option –
the Base SA chosen at inception (“Additional Sum Assured”) till the Under Life Plus Option, an amount equal to the 105% of the Total
earlier of: Premiums Paid (excluding loading for modal Premiums and discount, if
• The maximum sum assured eligibility as per the Underwriting any) shall be payable at the end of the Policy Term, provided the Life
Policy has reached; Insured survives till the Date of Maturity of Policy and the Policy is not
• The outstanding Premium Payment Term is less than 13 months; terminated earlier.

• The outstanding Policy Term is less than the minimum Policy Term Upon payment of this benefit, the Policy shall terminate and no other
allowed under this product; benefit shall be payable.
• The Age at the time of increase of Base SA is higher than the 3.1.2. Death Benefit
below Maximum Entry Age as applicable under the product
Life/Life Plus/Life Income option (as chosen)
(applicable as per the benefit option chosen by You at inception of
the Policy): On death of the Life Insured during the Policy Term where the Policy is in
force, We shall pay death benefit to the Claimant, which shall be highest of
Benefit Option Age
the following:
Life 65
a) 1.25 x Single Premium (excluding discount, if any) (where Single
Life Plus 65 Premium payment is opted) or Death Benefit Multiple1 x Annualised
or Premium2 (excluding discount, if any) (where Regular Premium
• Claim under Payor Accelerator Benefit. payment or Limited Premium payment is opted);

This is subject to the Underwriting Policy of the Company. b) 105% of Total Premiums Paid (excluding loading for modal Premiums
and discount, if any) up to date of death; or
You may opt to terminate the future increments at any time during
the Policy Term and such termination will be effective from the next c) An absolute amount assured to be paid on death3
Policy Anniversary. Once the future increments are terminated, it is 1
DB multiple is 7 in case of Life Option and 11 in case of Life Plus and Life
not possible to initiate the increments again over the remaining Income options (as chosen by You)
Premium Paying Term of the Policy. in aggregate for Base SA and all tranches of Additional Sum Assured (if
2

applicable)
In case You opt to terminate the future increments, You may opt to
surrender the Additional Sum Assured tranches (i.e. in multiples of
3
The absolute amount assured to be paid on death is the Effective Sum Assured
applicable as on the date of death.
5% of Base SA) at once or successively, after payment of
premiums for first five completed Policy Years. The Additional Sum Here, Effective Sum Assured shall depend on the plan option chosen,
Assured tranches shall be terminated after payment of any as below:
applicable value on surrender. The Additional Sum Assured
- For Life/Life Plus option - The Effective Sum Assured applicable
tranches will be surrendered in reverse order to which they were
for computation of Death Benefit would include any Additional
availed, i.e. the latest tranche will be surrendered first, followed by
Sum Assured purchased by exercising either the Life Stage or the
the penultimate tranche, and so on. This shall be allowed till all
Top-Up Sum Assured option along with the Base SA.
incremental Additional Sum Assured tranches are removed. Once
reduced, the Premium or sum assured cannot be subsequently - For Life Income option - The Effective Sum Assured applicable for
increased. The Policy shall continue with the Effective Sum computation of Death Benefit shall be the Base SA less total
Assured (as defined under Clause 3.1.2 ‘Death Benefit’ of Part C) Regular Income payouts due up to that time.
as applicable at the time of termination of the tranche(s) for rest of
In case of Life Income option, We shall adjust any excess Regular Income
the Policy Term.
payouts from the Death Benefit, in case any payments were made post
Under both Life Stage and Top-up Sum Assured option, an additional date of death.
Premium as may be applicable for each tranche of Additional Sum
Assured shall be payable by You and shall be determined using Additional Under Credit Protect option (as chosen)
Sum Assured and the Premium Rate which will be derived basis the
On death of the Life Insured during the Policy Term where the Policy is in
following:
force, We shall pay Effective Sum Assured as on the date of death to the
- Attained Age as of the Policy Anniversary as on the date of opting for Claimant, which shall be as below:
Additional Sum Assured, subject to the below Maximum Entry Age (as
on last birthday) as applicable under the product (applicable as per the The Effective Sum Assured (“Eff_SA”) applicable for computation of Death
benefit option chosen by You at inception of the Policy): Benefit at the start of month ‘t’ computed for an underlying interest rate ‘i’

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
p.a. is defined as per the formula below: 3.1.4. Survival Benefit (Applicable only if Life Income option is chosen)
Base SA if t =1 Provided the Policy is in force, You shall receive this benefit depending on the
Income Start Age and Income Rate (as defined below) chosen by the
i _ Base
Eff_SAt = Eff_SAt-1 (
* 1 + 12 )
___ SA ___
_________
1 __ vPT
( )i
* 12 if 1 < t ≤ PT and i > 0% Policyholder at the time of inception of the Policy. Starting at the end of every
month after the Policy Anniversary, following attainment of Income Start Age
Eff_SAt-1 __ Base SA
_________ if 1 < t ≤ PT and i = 0% by the Life Assured, the Regular Income (as defined below) shall be paid in
PT arrears until the death of the Life Assured or end of the Policy Term, whichever
Here: is earlier. All Regular Income payouts will be paid to the Policyholder.
o PT = Policy Term, in months In case the Life Assured survives till maturity, no additional benefit is payable
o v = (1 + i/12)-1 and the Policy shall terminate.
Here:
The above Death Benefit payable on death would be reduced by the claim • “Income Start Age” means the age of the Life Insured at which the
payout already made (if any) under Payor Accelerator Benefit. monthly Regular Income, if applicable, starts. The choices available
The Policy will terminate on payment of entire Death Benefit and no other are 55, 60 and 65 years, last birthday as selected by the Policyholder
benefits shall be payable under the Policy. at the time of inception of the Policy. Once selected, Income Start Age
cannot be changed.
3.1.2.1. Death Benefit Payout Plan
• “Income Rate” is a fixed rate of the Base SA which is used to
At the inception of the Policy, You may choose to receive the Death Benefit in determine the quantum of Regular Income payable to the Policyholder,
any one of the below options:
if applicable. The rate can be any percentage between 0.01% to
a) Lump Sum – Claimant shall receive the Death Benefit in lump sum. 0.15%, in increments of 0.01%, as selected by the Policyholder at the
b) Staggered Benefit – Claimant shall also receive staggered benefit for time of inception of the Policy. Once selected, the Income Rate cannot
chosen benefit period (up to maximum of 60 months) as per the be changed.
chosen frequency which can be Annual / Half Yearly / Quarterly / • “Regular Income” is the amount of monthly income payable from the
Monthly, starting from the modal anniversary following the date of Income Start Age and is set as Income Rate multiplied by Base SA.
occurrence of insured event. Any accrued staggered benefit, due
3.1.5. Optional Features
before intimation, will be paid along with first payout under this option.
c) Combination of Lump Sum and Staggered Benefit - The Death 3.1.5.1. Health Management Services:
Benefit shall be payable as per the chosen ratio of lump sum and The Life Insured may avail second opinion/personal medical case
income. Along with the lump sum amount, the Claimant shall also management services/medical consultation from the service provider/s
receive income for chosen benefit period (up to 60 months) as per the affiliated to/registered with Us. The services are expected to assist the Life
chosen frequency which can be Annual / Half Yearly / Quarterly / Insured to ascertain correct diagnosis of a medical condition and obtain due
Monthly, starting from the modal anniversary of the date of occurrence care to the Life Insured in case of illness. These services are subject to:
of insured event. Any accrued income, due before intimation, will be - the availability of a suitable service provider/s;
paid along with first payout under this option.
- primary diagnosis has been done by a registered medical practitioner
At any time during the chosen benefit period, the Claimant has an as may be authorized by a competent statutory authority; and
option to receive the commuted value of the future staggered benefits
- the eligibility of the Life Insured as may be determined as per the
as a lumpsum, discounted at the higher of –
Company’s Underwriting Policy.
- 4.00% p.a.; or Note:
- State Bank of India domestic 10-year term deposit rate prevailing - Medical Second Opinion/Personal Medical Case
at the time of commutation + 2.00%. Management/medical consultation is an optional service offered to
In case of death of the Life Assured after a valid claim under the Payor You at no additional cost. You may exercise Your own discretion to
accelerator benefit, the above Death Benefit shall be reduced by the avail the services and to follow the treatment path suggested by the
amount already paid under Payor Accelerator Benefit under Clause service provider/s.

3.1.3. Payor Accelerator Benefit - These services shall be directly provided by the service provider/s.
Upon diagnosis of Terminal Illness of the Life Insured, an amount equal to, - The services can be availed only where the policy is in force.
- Under Life/Life Plus option - 50% of the Base SA shall be payable as - All the supporting medical records should be available to avail the
lump sum. service.
- Under Life Income/Credit Protect option – 50% of the Effective Sum - We reserve the right to discontinue the service or change the service
Assured as defined under Clause 3.1.2 ‘Death Benefit’ of Part C (as on provider/s at any time.
the date of diagnosis) shall be payable as lump sum. If the stipulated - The services are being provided by third party service provider/s and
Death Benefit under Life Income option or Effective Sum Assured We will not be liable for any liability.
under Credit Protect option (Clause 3.1.2 ‘Death Benefit’ of Part C)
3.1.6. Premium details
falls below the Payor Accelerated Benefit already paid, the Policy shall
terminate and no additional benefit shall be payable. 3.1.6.1. Payment of Premium
Here: - You can pay Premium at any of Our offices or through our website
“Terminal Illness" is defined as an advanced or rapidly progressing incurable www.tataaia.com or by any other means, as informed by Us. Any
and un-correctable medical condition which, in the opinion of two (2) Premium paid by You will be deemed to have been received by Us only
independent Medical Practitioners specializing in treatment of such illness, has after the same has been realized and credited to Our bank account.
greater than 50% chance of death of the Life Insured within 6 months of the - Collection of advance premium shall be allowed within the same
date of diagnosis of the Terminal Illness. The Company reserves the right for
financial year for the Premium due in that financial year. However,
independent assessment of the Terminal Illness.
where the Premium due in one financial year is being collected in
The coverage under this benefit shall commence after 2 (two) years from the advance in earlier financial year, the Company may collect the same for
Date of Commencement of Policy. This is an accelerated benefit, i.e. on a maximum period of three months in advance of the due date of the
payment of this benefit, the Death Benefit shall be automatically reduced by Premium.
the amount paid under this benefit and the Policyholder shall continue to pay
all Premiums as due (if any) under the Policy. This benefit is not payable if the - The Premium so collected in advance shall only be adjusted on the
Policy is availed under Point of Sale product norms. due date of the Premium.
- Discount for Auto Premium Debit: An additional discount of 1% will be

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 offered on the first-year instalment due Premiums for all payments paid • Where at least 2 (two) Policy Years’ Premium have been paid –
through any permissible electronic mode debited through an Lapse Value shall be equal to -
auto-debit mandate. Such discount shall be capped to a maximum of Lapse Value Factor (LVF) * Total Premiums paid (excluding loading
r100 over the Policy Year. for modal premiums and discount, if any)
3.1.6.2. Change of frequency of Premium payment For a fully paid-up Policy, a positive Lapse Value is payable on surrender at
You may change the frequency of Premium payments by written request. any time after the payment of last due Premium. The Lapse Value Factor
Subject to our minimum Premium requirements and except in case of Single applicable at time (t) of surrender will depend on the Premium Paying Term
Pay, Premiums may be paid on monthly, quarterly, half-yearly or annual mode (PPT) and the Policy Term (PT), and is given by the following formula:
at the Premium rates applicable on the Date of Commencement of Policy.
Alteration in the frequency of Premium payment may lead to a change in the
Premium. No alterations are permissible under the Policy except change in
For Life Option,LVF= [ ( PPT PPT
t PT
)
0.5 * Min 1, ____ - ____ ]
frequency of Premium payment.
The loading on Premium shall be applicable as below:
[ (
PPT PPT
) ]
Effective SA
For Credit Protect Option,LVF= 0.5 * Min 1, ____ - ____ * _____________
t PT Base SA
c) Single Pay: Lapse Value will be equal to –
Mode Modal Loading
Lapse Value Factor (LVF) * Single Premium paid (excluding
Single Premium Multiply Annual Premium Rate by 1 (i.e. No loading) discount, if any)
Annual Multiply Annual Premium Rate by 1 (i.e. No loading) A positive Lapse Value is payable on surrender at any time after the
Half - Yearly Multiply Annual Premium Rate by 0.51 Premium is paid. The Lapse Value Factor applicable at time (t) of surrender
will depend on the Policy Term (PT) and is given by the following formula:
Quarterly Multiply Annual Premium Rate by 0.26
Monthly Multiply Annual Premium Rate by 0.0883 For Life Option,LVF= [ PT
t
]
0.5 * 1 _ ____
If the chosen premium paying term or policy term is not in integer years,
the permissible mode of premium payment shall be restricted to Single or For Credit Protect Option,LVF= [ t
] Effective SA
0.5 * 1 _ ____ * _____________
PT Base SA
Monthly only.
3.1.6.3. Grace period Such Lapse Value is determined separately for the Base SA and each
The Premium is due and payable by the due date specified in the tranche of Additional Sum Assured and all conditions are applicable for
Schedule. If the Premium is not paid by the due date, You may pay the each tranche separately. The total Lapse Value payable will be sum of such
same during the Grace Period without any interest. The Policy will remain computed Lapse Value for each tranche.
in force during this period. II. Life Plus/Life Income Option (as chosen)
During the Grace Period, if the overdue Premium is not paid and the Life
Insured dies, then We shall pay the Death Benefit Benefit after deducting the The Policy may be surrendered at any point during the Policy Term,
due Premium (without interest) for the Policy Year in which the death occurs. however it shall acquire a Surrender Value only if:

3.1.7. Payment of benefits - Single Premium – throughout the Policy Term;

- The benefit under the Policy shall be payable to the Claimant. - at least 2 (two) full years’ Premiums have been paid, in case of Policy
other than Single Premium
- Once the benefits under this Policy are paid to a Claimant, the same
shall constitute a valid discharge of Our liability under this Policy. The Surrender Value shall be equal to the higher of the Guaranteed
Surrender Value (GSV) and the Special Surrender Value (SSV).
3.1.8. Change in address of Policyholder or Nominee
In order to provide better services, We request you to intimate us in the event Here,
of any change in the address of the Policyholder or the Nominee. • Guaranteed Surrender Value (GSV) shall be the guaranteed
minimum non-negative value which is equal to
4. PART D
4.1. Free look period [GSV factor x Total Premiums paid (excluding loading for modal
premiums and discount, if any)] less total Regular Income already paid
You have a free look period of 15 days from the date of receipt of the policy (if applicable) up to the date of surrender
document and period of 30 days in case of policy obtained through
electronic or distance marketing mode, to review the terms and conditions The GSV factor (expressed as a percentage of the Total Premiums
of the Policy. If You disagree to any of these terms or conditions, You have Paid excluding loading for modal premiums and discount, if any) as
the option to return the Policy for cancellation, stating the reasons for specified in the Annexure A will depend on the Policy Year of surrender
objection and be entitled to a refund of the premiums paid without interest and the Policy Term.
after deduction of proportionate risk premium, stamp duty and medical • Special Surrender Value (SSV) may be declared by the Company.
examination cost along with applicable taxes, if any. Given that the underlying interest rate used reflects the prevailing
4.2. Non-forfeiture provisions market conditions, the Company may revise the SSV factors (if
declared) from time to time subject to the Asset and Liability
4.2.1. Surrender Benefit: (Where surrender value is payable)
committee’s (ALCO) approval. However, any change in the
Depending on the Plan Option chosen, the Surrender Benefit shall be methodology/formula for calculating SSV factors shall be subject to
as follows: IRDAI approval. Any change in SSV factors shall be filed with the
Authority and shall be intimated to You from time to time.
I. Life/Credit Protect Option (as chosen) –
The SSV will be as below:
The Policy may be surrendered at any point during the Policy Term,
however it shall acquire a Lapse Value only if: - Life Plus option: SSV factor x 105% of Total Premiums Paid
- Single Premium – throughout the Policy Term; (excluding loading for modal Premiums and discount, if any)
- at least 2 (two) full years’ Premiums have been paid, in case of - Life Income option: SSV factor x (Paid-Up Terminal Value less total
Policy other than Single Premium Regular Income already paid up to the date of surrender)
Applicable Lapse Value as per the Premium payment option chosen, The SSV factors provided are applicable at the end of the year and
shall be as below - shall be interpolated, on a daily basis, to arrive at the factors applicable
a) Regular Pay: Lapse Value will be zero. at the time of surrender.
b) Limited Pay: The Surrender Value shall be determined separately for the Base SA
• Where less than 2 (two) Policy Years’ Premium have been paid – and each tranche of Additional Sum Assured, wherever applicable.
Lapse Value will be zero. The total Surrender Value payable will be sum of such computed
Surrender Value for each tranche of Additional SA.

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
4.2.2. Lapsation of Policy Date of Maturity of Policy, subject to: (i) Your written application for revival;
If the Premium is not paid within the Grace Period and if the Policy has not (ii) production of Insured’s current health certificate and other evidence of
acquired Surrender Value, the Policy will lapse from the due date of first insurability; and (iii) payment of all overdue Premiums with interest.
unpaid Premium and no benefits will be payable. The applicable interest rate for revival is determined using the SBI (State
Bank of India) [or any other public sector undertaking bank] domestic term
4.3. Reduced Paid-up: (Applicable only under Life Plus/Life
deposit rate for tenure ‘1 year to less than 2 years’, plus 2%. The interest
Income Option as chosen)
rate applicable is reviewed every 6 months and gets updated as per the
Provided the Policy has acquired Surrender Value, if subsequent Premium given formula. Any alteration in the formula will be subject to prior approval
remain unpaid at the end of Grace Period, the Policy will be converted into of IRDAI. The simple interest rate applicable as on 1st October 2020, is
a Reduced Paid-up Policy by default. 6.90% p.a. [i.e. SBI interest rate of 4.90% (which rate may be revised from
Reduced Paid-up policy is a default non-forfeiture benefit. Reduced time to time) + 2%].
Paid-Up Policy, shall continue as Reduced Paid-up Policy unless revived Upon revival, the benefits of the Policy shall be restored with effect from the
within Revival Period by payment of all due Premiums together with date of revival.
interest as mentioned in Clause 4.4 (“Revival”) of Part D. However, where a
prior claim under Payor Accelerated Benefit has been paid, 5. PART E
- Policy shall continue provided the Reduced Paid-up Benefit is higher Not Applicable for this Product
than the Payor Accelerated Benefit claim amount already paid.
6. PART F
- Policy shall lapse if the Reduced Paid-up Benefit is lesser than the
6.1. Fraud, Misstatement and Suppression
Payor Accelerated Benefit claim amount already paid.
Any fraud, mis-statement or suppression of a material fact under the Policy
In case of Reduced Paid-up Policy, the benefit shall be payable as under: shall be dealt in accordance with Section 45 of the Insurance Act, 1938 as
4.3.1. In case of no prior claim under Payor Accelerated Benefit – amended from time to time.
a. Maturity Benefit: The simplified version of the provisions of Section 45 of the Insurance Act,
- Life Plus option: The benefit shall be equal to Maturity benefit as 1938 is enclosed in Annexure 4 for reference.
per Clause 3.1.1 of Part C. 6.2. Exclusions
- Life Income option: Paid-Up Terminal Value3 (as computed below) 6.2.1. Suicide
shall be paid.
In case of death due to suicide within 12 months:
b. Death Benefit: On death of the Life Insured during the Policy Term,
- from the Date of Commencement of Risk under the Policy or from the
We shall pay Reduced Paid-up Sum Assured1.
date of revival of the Policy, as applicable, the Claimant shall be entitled
c. Payor Accelerated Benefit: Upon diagnosis of Terminal Illness of the to at least 80% of the Total Premiums Paid till the date of death or the
Life Insured as per Clause 3.1.3 of Part C, We shall pay- Surrender Value available as on the date of death (if applicable)
- Life Plus option: 50% multiplied by Reduced Paid up Factor2 whichever is higher, provided the Policy is in force; OR
multiplied by Base SA - where the Life Stage Option has been chosen, from the date of
- Life Income option: 50% multiplied by Reduced Paid-up Factor2 exercising the Life Stage Option, the Claimant shall be entitled to 80%
multiplied by Effective SA of the Premiums paid (excluding applicable taxes, Rider Premiums and
Extra Premiums) for the increased tranche(s). The Death Benefit based
d. Survival Benefit: No survival benefit is payable.
on the Base SA and any Death Benefit increased by exercising the Life
4.3.2. In case of prior claim under Payor Accelerated Benefit – Stage Option subsequently but prior to 12 months from the date of
a. Maturity Benefit: death (due to suicide) will remain payable in full.
- Life Plus option: The benefit shall be equal to Maturity benefit as 6.2.2. Waiting Period (Applicable only if the Policy is availed under
per Clause 3.1.1. of Part C. Point of Sale product norms)
- Life Income option: Paid-Up Terminal Value3 (as computed below) If death of the Life Assured occurs during the Waiting Period, We shall
shall be paid. refund Total Premiums Paid and the Policy will terminate with immediate
effect. Waiting period shall not be applicable in case of death due to
b. Death Benefit: On death of the Life Insured during the Policy Term, accident provided all due Premiums have been paid.
We shall pay
6.2.3. Payor Accelerator Benefit
Reduced Paid-up Sum Assured1 minus the Payor Accelerated Benefit
amount already paid No claim shall be payable if the diagnosis of Terminal Illness of the Life
Insured arises directly or indirectly because of attempted suicide in the first
Here, year from inception or revival of the Policy. In case a claim under Payor
• Reduced Paid-Up Sum Assured is defined as –
1
Accelerator Benefit is not payable due to the above exclusion, the Policy
Sum of Reduced Paid-Up Factor multiplied by Sum Assured, determined shall continue with the applicable death cover.
separately for the Base SA and for each tranche of Additional Sum Assured.
6.3. Misstatement of Age
• 2
Reduced Paid-Up Factor (in respect of Base SA and each tranche) shall be
equal to – Declaration of the correct Age of the Life Insured is important for Our
underwriting process and calculation of Premiums payable under the
Total period for which Premiums have already been paid divided by the Policy. If the Age declared in the Proposal Form is found to be incorrect at
maximum period for which Premiums were originally payable
any time during the Policy Term or at the time of claim, We may revise the
• 3
Paid-up Terminal Value = Reduced Paid-Up Factor multiplied by Base SA Premium with interest and/or applicable benefits payable under the Policy
multiplied by [12 multiplied by Income Rate multiplied by (Maturity Age – Income in accordance with the Premium and benefits that would have been
Start Age)], where Maturity Age = Age (last birthday) of the Life Assured at Date payable, if the correct Age would have made the Life Insured eligible to be
of Maturity.
covered under the Policy on the Date of Commencement of Policy. If at the
c. Payor Accelerated Benefit: No benefit shall be payable. correct Age the Life Insured is not insurable under this Policy pursuant to
our Underwriting Policy, the Policy shall be void ab-initio and the Company
d. Survival Benefit: No survival benefit is payable. will refund the Total Premiums Paid without interest after deducting all
e. Surrender Benefit – This benefit is same as per Clause 4.2.1 of Part D. charges incurred by the Company under the Policy.
4.4. Revival 6.4. Nomination
If there is default in Premium Payment beyond the Grace Period and Nomination allowed as per provisions of Section 39 of the Insurance Act
subject to the Policy not having been surrendered, it may be revived, in 1938 as amended from time to time. The simplified version of the
accordance with Underwriting Policy within Revival Period but before the provisions of Section 39 is enclosed in Annexure 3 for reference.

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
6.5. Assignment Type of Claim Requirement
Assignment shall be as per Section 38 of the Insurance Act 1938 as 5. Cancelled cheque with name and account number
amended from time to time. The simplified version of the provisions of printed or cancelled cheque with copy of Bank
Section 38 is enclosed in Annexure 2 for reference.
Passbook / Bank Statement
6.6. Loss of Policy document Death
6. If no nomination - Proof of legal title to the claim
If the Policy document is lost or destroyed, then at the request of the (All causes of proceeds (e.g. legal succession paper)
death other than
Policyholder, the Company will issue a duplicate Policy document duly the Accidental Additional documents required on basis of cause of
endorsed to show that it is issued following the loss or destruction of the Death) death Medical/Natural death:
original Policy document. Upon the issuance of the duplicate Policy
document, the original Policy document immediately and automatically 1) Attending Physician's Statement
ceases to have any validity. The Company will charge a fee of R 250/- along 2) Medical Records (Admission Notes,
with the applicable tax and surcharge/cess, for the issuance of a duplicate Discharge/Death Summary, Indoor Case Papers,
Policy document. These charges are subject to revision by the Company Test Reports etc.)#
from time to time.
- Copy of the First Information Report (FIR) or
6.7. Taxes If Death due to Panchanama/Police complaint
All Premiums and interest payable under the policy are exclusive of Accident (to be
applicable taxes, duties, surcharge, cesses or levies which will be entirely submitted in - Copy of Post Mortem report (PMR)/Autopsy and
addition to the Viscera report
borne/ paid by the Policyholder, in addition to the payment of such above)
Premium or interest. Tata AIA Life shall have the right to claim, deduct, - Copy of the Final Police Investigation report
adjust and recover the amount of any applicable tax or imposition, levied (FPIR)/Charge sheet
by any statutory or administrative body, from the benefits payable under
Additional
the Policy. documents for
NRI (to be 1) FATCACRS self-certification forms Individual
6.8. Termination of Policy:
submitted in 2) FATCACRS self-certification forms Non-Individual
This Policy will terminate upon the happening of any of the following events: addition to the
above)
1. On the date of refund of Premium under Freelook request.
2. On the date of payment of the Maturity Benefit (if applicable), death
#
This is applicable if Life Assured was in hospital at the time of death or any time prior
to the date of death.
claim in accordance with the provisions of this Policy or date of
intimation of repudiation of claim by Us; Please submit copies of the following documents certified / attested by the
3. On the expiry of the Revival Period, if the Lapsed Policy has not been issuing authority. (Original Seen Verified (OSV) by Branch Personnel will
revived; also be accepted) –
4. On the date of payment of Surrender Benefit of this Policy; - All Police papers – Panchnama, Inquest, First Information Report and
Final Investigation Report.
5. On the date of payment of last income instalment under Death Benefit
(if chosen), - Medical Records (Admission Notes, Discharge/Death Summary,
Indoor Case Papers, Test Reports etc).
6. If the stipulated Death Benefit under Life Income option or Effective
Sum Assured under Credit Protect option (Clause 3.1.2 ‘Death - Postmortem report (Autopsy report) & Chemical Viscera report
Benefit’ of Part C) falls below the Payor Accelerated Benefit already (certified by Police / Magistrate / Court will also be accepted)
paid; or Copies of the other documents to be submitted by self-attestation of
7. On cancellation/ termination of this Policy by Us on grounds of fraud, the claimant
misstatement and suppression of a material fact established in terms of
Payor Accelerator Claim requirements
Section 45 of the Insurance Act, 1938 as amended from time to time.
Terminal illness should be confirmed by the treating specialist practitioner
6.9. Claims on his written statement
Notice of Claim – All cases of death must be notified, within a period of 90 along with relevant lab reports and other treatment papers which should
days, to us in writing. However, We may condone delay on merit for involve the below noting’s
delayed claims where the reason for delay is proved to be for reasons
beyond the control of the Claimant. In case of any delay on the part of the - If insured in undergoing palliative treatment or Curative care treatment
Company to process the claim within extant regulatory timeline, We shall - Status or stage of the disease
pay interest as may be prescribed by the IRDAI from time to time. - Prognosis of the illness
Please note that all death claims will be payable to the Claimant. Survival rate as per the diagnosis
Appropriate forms and supporting documents must be submitted, at the
Maturity Claim Requirements
Claimant’s expenses, within 90 days after the date the Insured event
happens, unless specified otherwise. A list of primary claim documents To ensure processing the maturity payout on or before the Maturity Date,
listing the normally required documents is attached to the Policy. We shall consider the bank account details available in Your Policy record.
Submission of the listed documents, forms or other proof, however, shall If there is any change, please submit below documents sufficiently in
not be construed as an admission of liabilities by the Company. advance, to enable us release the maturity payout on or before the
Maturity Date:
We reserve the right to require any additional proof and documents in
support of the claim. a) NEFT Form;
b) a cancelled cheque or copy of passbook with pre-printed name and
6.9.1. Claims requirements
bank account number, for payout through NEFT, and
Death claims requirements
c) a self-attested photo ID proof.
For processing the claim request under this Policy, we will require the
Note-
following documents:
• In case the claim warrants any additional requirement, We reserve the
Type of Claim Requirement right to call for the same.
1. Claimant Statement • Notification of claim & submission of the claim requirements does not
Death 2. Copy of Death Certificate issued by a local Munici- mean admission of the claim liability by the Company.
(All causes of pal Authority • No agent is authorized to admit any liabilities on behalf of the
death other than 3. Original Policy Document Company, nor to alter this list of documents or any claims
the Accidental requirements called for by the Company.
Death) 4. Copy of Claimant's Photo Identification Proof &
Current Address Proof (List of acceptable photo ID
and Address proofs)

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
6.10. Claims Intimation Process - In case customers wishes to contact us during the course of the
Mentioned below is a list of various mediums through which Claimant can assessment, they can contact us at any of the above mentioned
touch points.
contact us.
a. Online claim intimation at - All Tata AIA Life branches have a Grievance Redressal Officer
https://www.tataaia.com/claims/claims-process.html who can be contacted for any support during the grievance
redressal process
b. WhatsApp (SMS CLAIM) to 7045669966
2) Escalation Mechanism
c. Email – claims@tataaia.com or Customercare@tataaia.com
In case customers are not satisfied with the decision of the above offices,
d. Call our helpline number 1-860-266-9966 (local charges apply) or has not received any response within the stipulated timelines, they may
e. Visit any of our branch offices contact the following officials for resolution:
f. Write directly to us on following address: • 1st level of Escalation: Head - Customer Service
Tata AIA Life Insurance Company Limited • 2nd level of Escalation: Grievance Redressal Officer (GRO)
B - Wing, 9th Floor, I-Think Techno Campus, Behind TCS, Pokhran For escalations, customers can email to
Road No.2, Close to Eastern Express Highway, Thane (West) – 400 head.customerservice@tataaia.com or write to –
607, Maharashtra. Tata AIA Life Insurance Company Limited, B-Wing, 9th Floor, I-Think
6.11. Governing Law and Jurisdiction Techno Campus, Behind TCS, Pokhran Road No.2, Close to Eastern
Express Highway, Thane (West) – 400 607, Maharashtra
The Policy will be governed by and enforced in accordance with the laws
of India. The competent courts in India will have exclusive jurisdiction in all We request our customers to follow the escalation mechanism in case of
matters and causes arising out of the Policy. non-receipt of response or unsatisfactory response from the concerned
persons mentioned above.
6.12. Material Information & Disclosures
If you are not satisfied with the response or do not receive a response from
This Policy is issued on the basis of the information provided and us within 15 days, you may approach the Grievance Cell of the Insurance
disclosures made in the Proposal Form, in respect of the Life Insureds’ Regulatory and Development Authority of India (IRDAI) on the following
health, income, occupation, education, other existing life insurance contact details:
policies, etc. (as applicable) which are material and essential for the
IRDAI Grievance Call Centre (IGCC) TOLL FREE NO: 155255 or
issuance of the Policy. Sharing of any incorrect information/disclosures or
1800 4254 732
suppression of accurate facts by You, can result in cancellation of the
Policy and/or rejection of the claim during or after Your life time. Email ID: complaints@irdai.gov.in
You can also register your complaint online at
PART G http://www.igms.irda.gov.in/. Address for communication for complaints
by fax/paper:
CONSUMER INFORMATION
Consumer Affairs Department – Grievance Redressal Cell.,
POLICYHOLDER'S SERVICING
Insurance Regulatory and Development Authority of India,
With regards to any query or issue related to the Policy, the Policyholder
can contact the Company through the following service avenues Sy.No.115/1, Financial District, Nanakramguda, Gachibowli,
Hyderabad – 500 032.
• Contact your Tata AIA Life Agent/ Distributor 3) Insurance Ombudsman:
• Call our helpline number at 1-860-266-9966 (local charges apply) Where the redressal provided by the Company is not satisfactory despite
• E-mail us at customercare@tataaia.com the escalation above, the customer may represent the case to the
Ombudsman for Redressal of the grievance, if it pertains to the following:
• Visit the nearest the Tata AIA Life branch or CAMS Service Center - Delay in settlement of claim
• Log on to Online Customer Portal by visiting www.tataaia.com - Partial or total rejection of claim;
• Write to Us at – Tata AIA Life Insurance Company Limited B-Wing, - Dispute with regard to premium;
9th Floor, I-Think Techno Campus, Behind TCS, Pokhran Road No.2, - Misrepresentation of policy terms and conditions;
Close to Eastern Express Highway, Thane (West) – 400 607, - Legal construction of the policy in so far as dispute related to claim;
Maharashtra. - Grievance relating to policy servicing;
GRIEVANCE REDRESSAL PROCEDURE - Issuance of policy which is not in conformity with proposal form;
1) Resolution of Grievances - Non- issuance of your insurance document; and
- Any other matter resulting from the violation of provisions of the
Customers can register their grievances through multiple service avenues: Insurance Act, 1938 or the regulations, circulars, guidelines or
• Call our helpline number at 1-860-266-9966 (local charges apply) instructions issued by the IRDAI from time to time or the terms and
Email us at life.complaints@tataaia.com conditions of the policy contract, in so far as they relate to issues
mentioned hereinabove.
• Login to online policy account on www.tataaia.com Please refer to our website www.tataaia.com for further details in this
• Visit any of the nearest Tata AIA Life branches or CAMS Service regard. The list of Ombudsman address is attached as Annexure 1
Centers The complaint should be made in writing duly signed by the complainant
or through his legal heirs, nominee or assignee, and shall state clearly the
• Contact your Tata AIA Life Agent / Distributor name and address of the complainant, the name of the branch or office of
• Log on to IGMS website www.igms.irda.gov.in the insurer against whom the complaint is made, the facts giving rise to the
complaint, supported by documents, the nature and extent of the loss
• Write to us on the following address:
caused to the complainant and the relief sought from the Insurance
Grievance Redressal Department Tata AIA Life Insurance Company Ombudsman. As per provision 14(3) of the Insurance Ombudsman Rules,
Limited, B- wing, 9th Floor, I-Think Techno Campus, Behind TCS, 2017, the complaint to the Ombudsman can be made, within a period of
Pokhran Road No.2, Close to Eastern Express Highway, Thane (West) one year provided it is not simultaneously under any litigation:
– 400 607, Maharashtra. • Only if the grievance has been rejected by the Grievance Redressal
- We shall acknowledge a customer's grievance within 3 business Machinery of the Insurer; or
days by providing the customer with the name of the Grievance • the complainant had not received any reply within a period of one
Redressal Executive who is responsible to handle the grievance. month after the Insurer received his representation; or
- We shall provide the customer with an equitable resolution within • the complainant is not satisfied with the reply given to him by the
2 weeks of receipt of the grievance. Insurer.
Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 ANNEXURE A
SURRENDER VALUE FACTORS
GUARANTEED SURRENDER VALUE FACTORS:
Life Plus Plan Option – Single Pay

Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
2 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
3 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
4 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
5 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
6 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
7 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
8 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
9 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
10 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
11 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
12 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
13 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
14 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
15 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
16 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
17 90% 90% 90% 90% 90% 90% 90% 90% 90%
18 90% 90% 90% 90% 90% 90% 90% 90%
19 90% 90% 90% 90% 90% 90% 90%
20 90% 90% 90% 90% 90% 90%
21 90% 90% 90% 90% 90%
22 90% 90% 90% 90%
23 90% 90% 90%
24 90% 90%
25 90%
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Policy Years/Term 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
2 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
3 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%
4 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
5 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
6 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
7 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
8 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
9 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
10 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
11 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
12 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
13 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
14 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
15 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
16 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
17 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
18 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
19 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
20 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
21 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
22 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
23 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
24 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
25 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
26 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
27 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
28 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
29 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
30 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
31 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
32 90% 90% 90% 90% 90% 90% 90% 90% 90%
33 90% 90% 90% 90% 90% 90% 90% 90%
34 90% 90% 90% 90% 90% 90% 90%
35 90% 90% 90% 90% 90% 90%
36 90% 90% 90% 90% 90%
37 90% 90% 90% 90%
38 90% 90% 90%
39 90% 90%
40 90%

Life Plus Plan Option – Limited Pay / Regular Pay

Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30%
3 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
4 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
5 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
6 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
7 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
8 70% 63% 60% 58% 57% 56% 55% 54% 54% 54% 53% 53% 53% 53% 53% 52%
9 90% 77% 70% 66% 63% 61% 60% 59% 58% 57% 57% 56% 56% 55% 55% 55%
10 90% 90% 80% 74% 70% 67% 65% 63% 62% 61% 60% 59% 59% 58% 58% 57%
11 90% 90% 82% 77% 73% 70% 68% 66% 65% 63% 62% 61% 61% 60% 59%
12 90% 90% 83% 79% 75% 72% 70% 68% 67% 65% 64% 63% 63% 62%
13 90% 90% 84% 80% 77% 74% 72% 70% 68% 67% 66% 65% 64%
14 90% 90% 85% 81% 78% 75% 73% 72% 70% 69% 68% 66%
15 90% 90% 86% 82% 79% 77% 75% 73% 71% 70% 69%
16 90% 90% 86% 83% 80% 78% 76% 74% 73% 71%
17 90% 90% 86% 83% 81% 79% 77% 75% 74%
18 90% 90% 87% 84% 81% 79% 78% 76%
19 90% 90% 87% 84% 82% 80% 78%
20 90% 90% 87% 85% 83% 81%
21 90% 90% 87% 85% 83%
22 90% 90% 88% 85%
23 90% 90% 88%
24 90% 90%
25 90%
26
27
28
29
30
31
32
33
34
35

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
36
37
38
39
40

Policy Years/Term 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30%
3 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
4 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
5 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
6 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
7 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
8 52% 52% 52% 52% 52% 52% 52% 52% 52% 51% 51% 51% 51% 51% 51%
9 54% 54% 54% 54% 54% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53%
10 57% 56% 56% 56% 55% 55% 55% 55% 55% 54% 54% 54% 54% 54% 54%
11 59% 58% 58% 58% 57% 57% 57% 56% 56% 56% 56% 56% 55% 55% 55%
12 61% 61% 60% 60% 59% 59% 58% 58% 58% 57% 57% 57% 57% 56% 56%
13 63% 63% 62% 61% 61% 60% 60% 60% 59% 59% 59% 58% 58% 58% 58%
14 66% 65% 64% 63% 63% 62% 62% 61% 61% 60% 60% 60% 59% 59% 59%
15 68% 67% 66% 65% 65% 64% 63% 63% 62% 62% 61% 61% 61% 60% 60%
16 70% 69% 68% 67% 66% 66% 65% 64% 64% 63% 63% 62% 62% 62% 61%
17 72% 71% 70% 69% 68% 67% 67% 66% 65% 65% 64% 64% 63% 63% 63%
18 74% 73% 72% 71% 70% 69% 68% 68% 67% 66% 66% 65% 65% 64% 64%
19 77% 75% 74% 73% 72% 71% 70% 69% 68% 68% 67% 67% 66% 65% 65%
20 79% 77% 76% 75% 74% 73% 72% 71% 70% 69% 69% 68% 67% 67% 66%
21 81% 79% 78% 77% 75% 74% 73% 72% 72% 71% 70% 69% 69% 68% 67%
22 83% 82% 80% 79% 77% 76% 75% 74% 73% 72% 71% 71% 70% 69% 69%
23 86% 84% 82% 80% 79% 78% 77% 76% 75% 74% 73% 72% 71% 71% 70%
24 88% 86% 84% 82% 81% 80% 78% 77% 76% 75% 74% 73% 73% 72% 71%
25 90% 88% 86% 84% 83% 81% 80% 79% 78% 77% 76% 75% 74% 73% 72%
26 90% 90% 88% 86% 85% 83% 82% 80% 79% 78% 77% 76% 75% 75% 74%
27 90% 90% 88% 86% 85% 83% 82% 81% 80% 79% 78% 77% 76% 75%
28 90% 90% 88% 87% 85% 84% 82% 81% 80% 79% 78% 77% 76%
29 90% 90% 88% 87% 85% 84% 83% 81% 80% 79% 78% 77%
30 90% 90% 88% 87% 85% 84% 83% 82% 81% 80% 79%
31 90% 90% 88% 87% 86% 84% 83% 82% 81% 80%
32 90% 90% 88% 87% 86% 84% 83% 82% 81%
33 90% 90% 89% 87% 86% 85% 84% 82%
34 90% 90% 89% 87% 86% 85% 84%
35 90% 90% 89% 87% 86% 85%
36 90% 90% 89% 87% 86%
37 90% 90% 89% 87%
38 90% 90% 89%
39 90% 90%
40 90%

Life Income Option – Limited Pay

Policy Years/Term 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30%
3 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
4 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
5 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
6 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
7 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
8 53% 53% 53% 53% 53% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 51% 51%
9 57% 56% 56% 55% 55% 55% 54% 54% 54% 54% 54% 53% 53% 53% 53% 53% 53%
10 60% 59% 59% 58% 58% 57% 57% 56% 56% 56% 55% 55% 55% 55% 55% 54% 54%
11 63% 62% 61% 61% 60% 59% 59% 58% 58% 58% 57% 57% 57% 56% 56% 56% 56%
12 67% 65% 64% 63% 63% 62% 61% 61% 60% 60% 59% 59% 58% 58% 58% 57% 57%
13 70% 68% 67% 66% 65% 64% 63% 63% 62% 61% 61% 60% 60% 60% 59% 59% 59%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
14 73% 72% 70% 69% 68% 66% 66% 65% 64% 63% 63% 62% 62% 61% 61% 60% 60%
15 77% 75% 73% 71% 70% 69% 68% 67% 66% 65% 65% 64% 63% 63% 62% 62% 61%
16 80% 78% 76% 74% 73% 71% 70% 69% 68% 67% 66% 66% 65% 64% 64% 63% 63%
17 83% 81% 79% 77% 75% 74% 72% 71% 70% 69% 68% 67% 67% 66% 65% 65% 64%
18 87% 84% 81% 79% 78% 76% 74% 73% 72% 71% 70% 69% 68% 68% 67% 66% 66%
19 90% 87% 84% 82% 80% 78% 77% 75% 74% 73% 72% 71% 70% 69% 68% 68% 67%
20 90% 90% 87% 85% 83% 81% 79% 77% 76% 75% 74% 73% 72% 71% 70% 69% 69%
21 90% 90% 87% 85% 83% 81% 79% 78% 77% 75% 74% 73% 72% 72% 71% 70%
22 90% 90% 88% 85% 83% 82% 80% 79% 77% 76% 75% 74% 73% 72% 71%
23 90% 90% 88% 86% 84% 82% 80% 79% 78% 77% 76% 75% 74% 73%
24 90% 90% 88% 86% 84% 82% 81% 80% 78% 77% 76% 75% 74%
25 90% 90% 88% 86% 84% 83% 81% 80% 79% 78% 77% 76%
26 90% 90% 88% 86% 85% 83% 82% 80% 79% 78% 77%
27 90% 90% 88% 86% 85% 83% 82% 81% 80% 79%
28 90% 90% 88% 87% 85% 84% 82% 81% 80%
29 90% 90% 88% 87% 85% 84% 83% 81%
30 90% 90% 88% 87% 85% 84% 83%
31 90% 90% 88% 87% 86% 84%
32 90% 90% 88% 87% 86%
33 90% 90% 89% 87%
34 90% 90% 89%
35 90% 90%
36 90%
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30%
3 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
4 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
5 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
6 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
7 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
8 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51%
9 53% 53% 53% 53% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52%
10 54% 54% 54% 54% 54% 54% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53%
11 56% 55% 55% 55% 55% 55% 55% 54% 54% 54% 54% 54% 54% 54% 54% 54% 54%
12 57% 57% 56% 56% 56% 56% 56% 56% 55% 55% 55% 55% 55% 55% 55% 55% 54%
13 58% 58% 58% 58% 57% 57% 57% 57% 56% 56% 56% 56% 56% 56% 56% 55% 55%
14 60% 59% 59% 59% 58% 58% 58% 58% 58% 57% 57% 57% 57% 57% 57% 56% 56%
15 61% 61% 60% 60% 60% 59% 59% 59% 59% 58% 58% 58% 58% 58% 57% 57% 57%
16 62% 62% 62% 61% 61% 61% 60% 60% 60% 59% 59% 59% 59% 59% 58% 58% 58%
17 64% 63% 63% 63% 62% 62% 61% 61% 61% 61% 60% 60% 60% 60% 59% 59% 59%
18 65% 65% 64% 64% 63% 63% 63% 62% 62% 62% 61% 61% 61% 60% 60% 60% 60%
19 67% 66% 65% 65% 65% 64% 64% 63% 63% 63% 62% 62% 62% 61% 61% 61% 61%
20 68% 67% 67% 66% 66% 65% 65% 64% 64% 64% 63% 63% 63% 62% 62% 62% 62%
21 69% 69% 68% 67% 67% 66% 66% 66% 65% 65% 64% 64% 64% 63% 63% 63% 62%
22 71% 70% 69% 69% 68% 68% 67% 67% 66% 66% 65% 65% 65% 64% 64% 64% 63%
23 72% 71% 71% 70% 69% 69% 68% 68% 67% 67% 66% 66% 66% 65% 65% 65% 64%
24 73% 73% 72% 71% 71% 70% 69% 69% 68% 68% 67% 67% 67% 66% 66% 65% 65%
25 75% 74% 73% 72% 72% 71% 71% 70% 69% 69% 68% 68% 68% 67% 67% 66% 66%
26 76% 75% 75% 74% 73% 72% 72% 71% 71% 70% 69% 69% 69% 68% 68% 67% 67%
27 78% 77% 76% 75% 74% 74% 73% 72% 72% 71% 71% 70% 70% 69% 69% 68% 68%
28 79% 78% 77% 76% 75% 75% 74% 73% 73% 72% 72% 71% 70% 70% 70% 69% 69%
29 80% 79% 78% 77% 77% 76% 75% 74% 74% 73% 73% 72% 71% 71% 70% 70% 70%
30 82% 81% 80% 79% 78% 77% 76% 76% 75% 74% 74% 73% 72% 72% 71% 71% 70%
31 83% 82% 81% 80% 79% 78% 77% 77% 76% 75% 75% 74% 73% 73% 72% 72% 71%
32 84% 83% 82% 81% 80% 79% 79% 78% 77% 76% 76% 75% 74% 74% 73% 73% 72%
33 86% 85% 84% 82% 82% 81% 80% 79% 78% 77% 77% 76% 75% 75% 74% 74% 73%
34 87% 86% 85% 84% 83% 82% 81% 80% 79% 78% 78% 77% 76% 76% 75% 75% 74%
35 89% 87% 86% 85% 84% 83% 82% 81% 80% 79% 79% 78% 77% 77% 76% 75% 75%
36 90% 89% 87% 86% 85% 84% 83% 82% 81% 81% 80% 79% 78% 78% 77% 76% 76%
37 90% 90% 89% 87% 86% 85% 84% 83% 82% 82% 81% 80% 79% 79% 78% 77% 77%
38 90% 90% 89% 88% 86% 85% 84% 84% 83% 82% 81% 80% 80% 79% 78% 78%
39 90% 90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 80% 80% 79% 78%
40 90% 90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 81% 80% 79%
41 90% 90% 89% 88% 87% 86% 85% 84% 83% 82% 82% 81% 80%
42 90% 90% 89% 88% 87% 86% 85% 84% 83% 83% 82% 81%
43 90% 90% 89% 88% 87% 86% 85% 84% 83% 83% 82%
44 90% 90% 89% 88% 87% 86% 85% 84% 84% 83%
45 90% 90% 89% 88% 87% 86% 85% 85% 84%
46 90% 90% 89% 88% 87% 86% 85% 85%
47 90% 90% 89% 88% 87% 86% 86%
48 90% 90% 89% 88% 87% 86%
49 90% 90% 89% 88% 87%
50 90% 90% 89% 88%
51 90% 90% 89%
52 90% 90%
53 90%
54
55
56
57
58
59
60
61
62
63

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
64
65
66
67
68
69
70

Policy Years/Term 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30% 30%
3 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35% 35%
4 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
5 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
6 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
7 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
8 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51% 51%
9 52% 52% 52% 52% 52% 52% 52% 52% 51% 51% 51% 51% 51% 51% 51% 51% 51%
10 53% 53% 53% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52% 52%
11 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53% 53%
12 54% 54% 54% 54% 54% 54% 54% 54% 54% 54% 54% 54% 53% 53% 53% 53% 53%
13 55% 55% 55% 55% 55% 55% 55% 55% 54% 54% 54% 54% 54% 54% 54% 54% 54%
14 56% 56% 56% 56% 56% 55% 55% 55% 55% 55% 55% 55% 55% 55% 55% 55% 55%
15 57% 57% 57% 57% 56% 56% 56% 56% 56% 56% 56% 56% 56% 55% 55% 55% 55%
16 58% 58% 58% 57% 57% 57% 57% 57% 57% 57% 56% 56% 56% 56% 56% 56% 56%
17 59% 59% 58% 58% 58% 58% 58% 58% 57% 57% 57% 57% 57% 57% 57% 57% 56%
18 60% 59% 59% 59% 59% 59% 58% 58% 58% 58% 58% 58% 58% 57% 57% 57% 57%
19 60% 60% 60% 60% 60% 59% 59% 59% 59% 59% 59% 58% 58% 58% 58% 58% 58%
20 61% 61% 61% 61% 60% 60% 60% 60% 60% 59% 59% 59% 59% 59% 59% 59% 58%
21 62% 62% 62% 61% 61% 61% 61% 61% 60% 60% 60% 60% 60% 59% 59% 59% 59%
22 63% 63% 63% 62% 62% 62% 62% 61% 61% 61% 61% 61% 60% 60% 60% 60% 60%
23 64% 64% 63% 63% 63% 63% 62% 62% 62% 62% 61% 61% 61% 61% 61% 60% 60%
24 65% 64% 64% 64% 64% 63% 63% 63% 63% 62% 62% 62% 62% 62% 61% 61% 61%
25 66% 65% 65% 65% 64% 64% 64% 64% 63% 63% 63% 63% 62% 62% 62% 62% 62%
26 67% 66% 66% 66% 65% 65% 65% 64% 64% 64% 64% 63% 63% 63% 63% 62% 62%
27 67% 67% 67% 66% 66% 66% 65% 65% 65% 65% 64% 64% 64% 64% 63% 63% 63%
28 68% 68% 67% 67% 67% 66% 66% 66% 66% 65% 65% 65% 64% 64% 64% 64% 64%
29 69% 69% 68% 68% 68% 67% 67% 67% 66% 66% 66% 65% 65% 65% 65% 64% 64%
30 70% 70% 69% 69% 68% 68% 68% 67% 67% 67% 66% 66% 66% 66% 65% 65% 65%
31 71% 70% 70% 70% 69% 69% 68% 68% 68% 67% 67% 67% 67% 66% 66% 66% 65%
32 72% 71% 71% 70% 70% 70% 69% 69% 69% 68% 68% 68% 67% 67% 67% 66% 66%
33 73% 72% 72% 71% 71% 70% 70% 70% 69% 69% 69% 68% 68% 68% 67% 67% 67%
34 73% 73% 72% 72% 72% 71% 71% 70% 70% 70% 69% 69% 69% 68% 68% 68% 67%
35 74% 74% 73% 73% 72% 72% 72% 71% 71% 70% 70% 70% 69% 69% 69% 68% 68%
36 75% 75% 74% 74% 73% 73% 72% 72% 71% 71% 71% 70% 70% 70% 69% 69% 69%
37 76% 76% 75% 74% 74% 74% 73% 73% 72% 72% 71% 71% 71% 70% 70% 70% 69%
38 77% 76% 76% 75% 75% 74% 74% 73% 73% 73% 72% 72% 71% 71% 71% 70% 70%
39 78% 77% 77% 76% 76% 75% 75% 74% 74% 73% 73% 72% 72% 72% 71% 71% 71%
40 79% 78% 77% 77% 76% 76% 75% 75% 74% 74% 74% 73% 73% 72% 72% 72% 71%
41 80% 79% 78% 78% 77% 77% 76% 76% 75% 75% 74% 74% 73% 73% 73% 72% 72%
42 80% 80% 79% 79% 78% 77% 77% 76% 76% 75% 75% 75% 74% 74% 73% 73% 73%
43 81% 81% 80% 79% 79% 78% 78% 77% 77% 76% 76% 75% 75% 74% 74% 74% 73%
44 82% 81% 81% 80% 80% 79% 78% 78% 77% 77% 76% 76% 76% 75% 75% 74% 74%
45 83% 82% 82% 81% 80% 80% 79% 79% 78% 78% 77% 77% 76% 76% 75% 75% 75%
46 84% 83% 82% 82% 81% 81% 80% 79% 79% 78% 78% 77% 77% 76% 76% 76% 75%
47 85% 84% 83% 83% 82% 81% 81% 80% 80% 79% 79% 78% 78% 77% 77% 76% 76%
48 86% 85% 84% 83% 83% 82% 82% 81% 80% 80% 79% 79% 78% 78% 77% 77% 76%
49 87% 86% 85% 84% 84% 83% 82% 82% 81% 81% 80% 79% 79% 78% 78% 78% 77%
50 87% 87% 86% 85% 84% 84% 83% 82% 82% 81% 81% 80% 80% 79% 79% 78% 78%
51 88% 87% 87% 86% 85% 85% 84% 83% 83% 82% 81% 81% 80% 80% 79% 79% 78%
52 89% 88% 87% 87% 86% 85% 85% 84% 83% 83% 82% 82% 81% 81% 80% 80% 79%
53 90% 89% 88% 88% 87% 86% 85% 85% 84% 83% 83% 82% 82% 81% 81% 80% 80%
54 90% 90% 89% 88% 88% 87% 86% 85% 85% 84% 84% 83% 82% 82% 81% 81% 80%
55 90% 90% 89% 88% 88% 87% 86% 86% 85% 84% 84% 83% 83% 82% 81% 81%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 Policy Years/Term 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
56 90% 90% 89% 88% 88% 87% 86% 86% 85% 84% 84% 83% 83% 82% 82%
57 90% 90% 89% 88% 88% 87% 86% 86% 85% 84% 84% 83% 83% 82%
58 90% 90% 89% 88% 88% 87% 86% 86% 85% 85% 84% 83% 83%
59 90% 90% 89% 89% 88% 87% 86% 86% 85% 85% 84% 84%
60 90% 90% 89% 89% 88% 87% 87% 86% 85% 85% 84%
61 90% 90% 89% 89% 88% 87% 87% 86% 85% 85%
62 90% 90% 89% 89% 88% 87% 87% 86% 85%
63 90% 90% 89% 89% 88% 87% 87% 86%
64 90% 90% 89% 89% 88% 87% 87%
65 90% 90% 89% 89% 88% 87%
66 90% 90% 89% 89% 88%
67 90% 90% 89% 89%
68 90% 90% 89%
69 90% 90%
70 90%

SPECIAL SURRENDER VALUE FACTORS:

Life Plus Plan Option – Single Pay

Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 52% 49% 45% 42% 39% 37% 34% 32% 29% 27% 26% 24% 22% 21% 19% 18%
2 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22% 21% 19%
3 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22% 21%
4 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22%
5 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24%
6 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26%
7 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28%
8 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30%
9 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32%
10 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34%
11 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37%
12 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39%
13 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42%
14 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 46%
15 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49%
16 100% 93% 87% 81% 75% 70% 65% 60% 56% 52%
17 100% 93% 87% 81% 75% 70% 65% 60% 56%
18 100% 93% 87% 81% 75% 70% 65% 61%
19 100% 93% 87% 81% 75% 70% 65%
20 100% 93% 87% 81% 75% 70%
21 100% 93% 87% 81% 75%
22 100% 93% 87% 81%
23 100% 93% 87%
24 100% 93%
25 100%
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1 17% 16% 15% 14% 13% 12% 11% 11% 10% 9% 9% 8% 8% 7% 7%
2 18% 17% 16% 15% 14% 13% 12% 11% 11% 10% 10% 9% 8% 8% 8%
3 19% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9% 9% 8%
4 21% 20% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9% 9%
5 22% 21% 20% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9%
6 24% 22% 21% 20% 18% 17% 16% 15% 14% 13% 13% 12% 11% 11% 10%
7 26% 24% 23% 21% 20% 18% 17% 16% 15% 14% 13% 13% 12% 11% 11%
8 28% 26% 24% 23% 21% 20% 19% 17% 16% 15% 14% 14% 13% 12% 11%
9 30% 28% 26% 24% 23% 21% 20% 19% 17% 16% 15% 15% 14% 13% 12%
10 32% 30% 28% 26% 24% 23% 21% 20% 19% 18% 17% 16% 15% 14% 13%
11 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 18% 17% 16% 15% 14%
12 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17% 16% 15%
13 40% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17% 16%
14 42% 40% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17%
15 46% 42% 40% 37% 35% 32% 30% 28% 26% 25% 23% 22% 21% 19% 18%
16 49% 46% 43% 40% 37% 35% 32% 30% 28% 27% 25% 23% 22% 21% 20%
17 53% 49% 46% 43% 40% 37% 35% 32% 30% 28% 27% 25% 24% 22% 21%
18 56% 53% 49% 46% 43% 40% 37% 35% 33% 30% 29% 27% 25% 24% 22%
19 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27% 25% 24%
20 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27% 25%
21 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27%
22 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 38% 35% 33% 31% 29%
23 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35% 33% 31%
24 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35% 33%
25 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35%
26 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38%
27 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 41%
28 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50% 46% 43%
29 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50% 46%
30 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50%
31 100% 93% 87% 81% 75% 70% 65% 61% 57% 53%
32 100% 93% 87% 81% 75% 70% 65% 61% 57%
33 100% 93% 87% 81% 75% 70% 65% 61%
34 100% 93% 87% 81% 75% 70% 65%
35 100% 93% 87% 81% 75% 70%
36 100% 93% 87% 81% 75%
37 100% 93% 87% 81%
38 100% 93% 87%
39 100% 93%
40 100%

Life Plus Plan Option – Limited Pay / Regular Pay

Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22% 21% 19%
3 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22% 21%
4 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 22%
5 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24%
6 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26%
7 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28%
8 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32% 30%
9 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34% 32%
10 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37% 34%
11 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39% 37%
12 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42% 39%
13 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 45% 42%
14 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49% 46%
15 100% 93% 87% 81% 75% 70% 65% 60% 56% 52% 49%
16 100% 93% 87% 81% 75% 70% 65% 60% 56% 52%
17 100% 93% 87% 81% 75% 70% 65% 60% 56%
18 100% 93% 87% 81% 75% 70% 65% 61%
19 100% 93% 87% 81% 75% 70% 65%
20 100% 93% 87% 81% 75% 70%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
21 100% 93% 87% 81% 75%
22 100% 93% 87% 81%
23 100% 93% 87%
24 100% 93%
25 100%
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Policy Years/Term 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 18% 17% 16% 15% 14% 13% 12% 11% 11% 10% 10% 9% 8% 8% 8%
3 19% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9% 9% 8%
4 21% 20% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9% 9%
5 22% 21% 20% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10% 10% 9%
6 24% 22% 21% 20% 18% 17% 16% 15% 14% 13% 13% 12% 11% 11% 10%
7 26% 24% 23% 21% 20% 18% 17% 16% 15% 14% 13% 13% 12% 11% 11%
8 28% 26% 24% 23% 21% 20% 19% 17% 16% 15% 14% 14% 13% 12% 11%
9 30% 28% 26% 24% 23% 21% 20% 19% 17% 16% 15% 15% 14% 13% 12%
10 32% 30% 28% 26% 24% 23% 21% 20% 19% 18% 17% 16% 15% 14% 13%
11 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 18% 17% 16% 15% 14%
12 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17% 16% 15%
13 40% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17% 16%
14 42% 40% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19% 18% 17%
15 46% 42% 40% 37% 35% 32% 30% 28% 26% 25% 23% 22% 21% 19% 18%
16 49% 46% 43% 40% 37% 35% 32% 30% 28% 27% 25% 23% 22% 21% 20%
17 53% 49% 46% 43% 40% 37% 35% 32% 30% 28% 27% 25% 24% 22% 21%
18 56% 53% 49% 46% 43% 40% 37% 35% 33% 30% 29% 27% 25% 24% 22%
19 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27% 25% 24%
20 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27% 25%
21 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31% 29% 27%
22 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 38% 35% 33% 31% 29%
23 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35% 33% 31%
24 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35% 33%
25 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38% 35%
26 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40% 38%
27 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 41%
28 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50% 46% 43%
29 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50% 46%
30 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 50%
31 100% 93% 87% 81% 75% 70% 65% 61% 57% 53%
32 100% 93% 87% 81% 75% 70% 65% 61% 57%
33 100% 93% 87% 81% 75% 70% 65% 61%
34 100% 93% 87% 81% 75% 70% 65%
35 100% 93% 87% 81% 75% 70%
36 100% 93% 87% 81% 75%
37 100% 93% 87% 81%
38 100% 93% 87%
39 100% 93%
40 100%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Life Income Option – Limited Pay
Policy Years/Term 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 28% 26% 24% 22% 21% 19% 18% 17% 16% 15% 14% 13% 12% 11% 11% 10% 10%
3 30% 28% 26% 24% 22% 21% 19% 18% 17% 16% 15% 14% 13% 12% 12% 11% 10%
4 32% 30% 28% 26% 24% 22% 21% 20% 18% 17% 16% 15% 14% 13% 12% 12% 11%
5 34% 32% 30% 28% 26% 24% 22% 21% 20% 18% 17% 16% 15% 14% 13% 12% 12%
6 37% 34% 32% 30% 28% 26% 24% 22% 21% 20% 18% 17% 16% 15% 14% 13% 13%
7 39% 37% 34% 32% 30% 28% 26% 24% 23% 21% 20% 18% 17% 16% 15% 14% 13%
8 42% 39% 37% 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 17% 16% 15% 14%
9 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 17% 16% 15%
10 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 18% 17%
11 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 24% 23% 21% 20% 19% 18%
12 56% 52% 49% 45% 42% 39% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20% 19%
13 60% 56% 52% 49% 45% 42% 40% 37% 34% 32% 30% 28% 26% 25% 23% 22% 20%
14 65% 60% 56% 52% 49% 46% 42% 40% 37% 34% 32% 30% 28% 26% 25% 23% 22%
15 70% 65% 60% 56% 52% 49% 46% 42% 40% 37% 35% 32% 30% 28% 26% 25% 23%
16 75% 70% 65% 60% 56% 52% 49% 46% 43% 40% 37% 35% 32% 30% 28% 27% 25%
17 81% 75% 70% 65% 60% 56% 53% 49% 46% 43% 40% 37% 35% 32% 30% 28% 27%
18 87% 81% 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 30% 29%
19 93% 87% 81% 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33% 31%
20 100% 93% 87% 81% 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35% 33%
21 100% 93% 87% 81% 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 37% 35%
22 100% 93% 87% 81% 75% 70% 65% 61% 56% 53% 49% 46% 43% 40% 38%
23 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43% 40%
24 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46% 43%
25 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49% 46%
26 100% 93% 87% 81% 75% 70% 65% 61% 57% 53% 49%
27 100% 93% 87% 81% 75% 70% 65% 61% 57% 53%
28 100% 93% 87% 81% 75% 70% 65% 61% 57%
29 100% 93% 87% 81% 75% 70% 65% 61%
30 100% 93% 87% 81% 75% 70% 65%
31 100% 93% 87% 81% 75% 70%
32 100% 93% 87% 81% 75%
33 100% 93% 87% 81%
34 100% 93% 87%
35 100% 93%
36 100%
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
63
64
65
66
67
68
69
70

Policy Years/Term 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 9% 8% 8% 8% 7% 7% 6% 6% 6% 6% 5% 5% 5% 5% 5% 5% 4%
3 10% 9% 9% 8% 8% 7% 7% 7% 6% 6% 6% 6% 5% 5% 5% 5% 5%
4 10% 10% 9% 9% 8% 8% 7% 7% 7% 6% 6% 6% 6% 6% 5% 5% 5%
5 11% 10% 10% 9% 9% 8% 8% 8% 7% 7% 7% 6% 6% 6% 6% 6% 5%
6 12% 11% 11% 10% 9% 9% 8% 8% 8% 7% 7% 7% 6% 6% 6% 6% 6%
7 13% 12% 11% 11% 10% 10% 9% 9% 8% 8% 8% 7% 7% 7% 6% 6% 6%
8 14% 13% 12% 11% 11% 10% 10% 9% 9% 8% 8% 8% 7% 7% 7% 7% 6%
9 15% 14% 13% 12% 12% 11% 10% 10% 9% 9% 9% 8% 8% 8% 7% 7% 7%
10 16% 15% 14% 13% 12% 12% 11% 11% 10% 10% 9% 9% 8% 8% 8% 8% 7%
11 17% 16% 15% 14% 13% 12% 12% 11% 11% 10% 10% 9% 9% 9% 8% 8% 8%
12 18% 17% 16% 15% 14% 13% 13% 12% 11% 11% 10% 10% 10% 9% 9% 9% 8%
13 19% 18% 17% 16% 15% 14% 14% 13% 12% 12% 11% 11% 10% 10% 9% 9% 9%
14 20% 19% 18% 17% 16% 15% 14% 14% 13% 12% 12% 11% 11% 10% 10% 10% 9%
15 22% 21% 19% 18% 17% 16% 15% 15% 14% 13% 13% 12% 12% 11% 11% 10% 10%
16 23% 22% 21% 20% 18% 17% 16% 16% 15% 14% 13% 13% 12% 12% 11% 11% 11%
17 25% 24% 22% 21% 20% 19% 18% 17% 16% 15% 14% 14% 13% 13% 12% 12% 11%
18 27% 25% 24% 22% 21% 20% 19% 18% 17% 16% 15% 15% 14% 13% 13% 12% 12%
19 29% 27% 25% 24% 22% 21% 20% 19% 18% 17% 16% 16% 15% 14% 14% 13% 13%
20 31% 29% 27% 25% 24% 23% 21% 20% 19% 18% 17% 17% 16% 15% 15% 14% 14%
21 33% 31% 29% 27% 26% 24% 23% 22% 20% 19% 18% 18% 17% 16% 16% 15% 14%
22 35% 33% 31% 29% 27% 26% 24% 23% 22% 21% 20% 19% 18% 17% 16% 16% 15%
23 38% 35% 33% 31% 29% 28% 26% 25% 23% 22% 21% 20% 19% 18% 17% 17% 16%
24 40% 38% 35% 33% 31% 29% 28% 26% 25% 23% 22% 21% 20% 19% 19% 18% 17%
25 43% 40% 38% 35% 33% 31% 30% 28% 26% 25% 24% 23% 21% 21% 20% 19% 18%
26 46% 43% 40% 38% 36% 33% 32% 30% 28% 27% 25% 24% 23% 22% 21% 20% 19%
27 49% 46% 43% 41% 38% 36% 34% 32% 30% 28% 27% 25% 24% 23% 22% 21% 21%
28 53% 50% 46% 43% 41% 38% 36% 34% 32% 30% 29% 27% 26% 25% 24% 23% 22%
29 57% 53% 50% 46% 44% 41% 38% 36% 34% 32% 30% 29% 27% 26% 25% 24% 23%
30 61% 57% 53% 50% 47% 44% 41% 39% 36% 34% 32% 31% 29% 28% 27% 25% 25%
31 65% 61% 57% 53% 50% 47% 44% 41% 39% 37% 35% 33% 31% 30% 28% 27% 26%
32 70% 65% 61% 57% 53% 50% 47% 44% 41% 39% 37% 35% 33% 31% 30% 29% 28%
33 75% 70% 65% 61% 57% 53% 50% 47% 44% 42% 39% 37% 35% 33% 32% 30% 29%
34 81% 75% 70% 65% 61% 57% 54% 50% 47% 44% 42% 39% 37% 36% 34% 32% 31%
35 87% 81% 75% 70% 65% 61% 57% 54% 50% 47% 45% 42% 40% 38% 36% 34% 33%
36 93% 87% 81% 75% 70% 66% 61% 57% 54% 51% 48% 45% 42% 40% 38% 36% 35%
37 100% 93% 87% 81% 75% 70% 66% 61% 57% 54% 51% 48% 45% 43% 41% 39% 37%
38 100% 93% 87% 81% 75% 70% 66% 61% 58% 54% 51% 48% 45% 43% 41% 39%
39 100% 93% 87% 81% 75% 70% 66% 62% 58% 54% 51% 48% 46% 44% 42%
40 100% 93% 87% 81% 75% 70% 66% 62% 58% 55% 52% 49% 46% 44%
41 100% 93% 87% 81% 75% 70% 66% 62% 58% 55% 52% 49% 47%
42 100% 93% 87% 81% 75% 71% 66% 62% 58% 55% 52% 50%
43 100% 93% 87% 81% 75% 71% 66% 62% 59% 56% 53%
44 100% 93% 87% 81% 76% 71% 66% 63% 59% 56%
45 100% 93% 87% 81% 76% 71% 67% 63% 60%
46 100% 93% 87% 81% 76% 71% 67% 64%
47 100% 93% 87% 81% 76% 71% 67%
48 100% 93% 87% 81% 76% 72%
49 100% 93% 87% 81% 76%
50 100% 93% 87% 81%
51 100% 93% 87%
52 100% 93%
53 100%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
Policy Years/Term 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70

Policy Years/Term 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
1 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
2 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4%
3 5% 5% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4%
4 5% 5% 5% 5% 5% 5% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4%
5 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
6 6% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
7 6% 6% 6% 6% 6% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
8 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6%
9 7% 7% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6%
10 7% 7% 7% 7% 7% 7% 7% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6%
11 8% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7%
12 8% 8% 8% 8% 8% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7% 7%
13 9% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8%
14 9% 9% 9% 9% 9% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8%
15 10% 10% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%
16 10% 10% 10% 10% 10% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%
17 11% 11% 11% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10%
18 12% 11% 11% 11% 11% 11% 11% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10%
19 12% 12% 12% 12% 11% 11% 11% 11% 11% 11% 11% 11% 11% 11% 11% 11% 11%
20 13% 13% 13% 12% 12% 12% 12% 12% 12% 12% 12% 12% 11% 11% 11% 11% 11%
21 14% 14% 13% 13% 13% 13% 13% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12%
22 15% 14% 14% 14% 14% 13% 13% 13% 13% 13% 13% 13% 13% 13% 13% 13% 13%
23 16% 15% 15% 15% 14% 14% 14% 14% 14% 14% 14% 14% 14% 14% 14% 14% 14%
24 17% 16% 16% 16% 15% 15% 15% 15% 15% 14% 14% 14% 14% 14% 14% 14% 14%
25 18% 17% 17% 16% 16% 16% 16% 16% 15% 15% 15% 15% 15% 15% 15% 15% 15%
26 19% 18% 18% 17% 17% 17% 17% 16% 16% 16% 16% 16% 16% 16% 16% 16% 16%
27 20% 19% 19% 18% 18% 18% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17%
28 21% 20% 20% 19% 19% 19% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18%
29 22% 22% 21% 21% 20% 20% 20% 19% 19% 19% 19% 19% 19% 19% 19% 19% 19%
30 24% 23% 22% 22% 21% 21% 21% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
31 25% 24% 24% 23% 23% 22% 22% 22% 21% 21% 21% 21% 21% 21% 21% 21% 21%
32 27% 26% 25% 24% 24% 23% 23% 23% 23% 22% 22% 22% 22% 22% 22% 22% 22%
33 28% 27% 26% 26% 25% 25% 24% 24% 24% 24% 24% 24% 24% 23% 23% 23% 23%
34 30% 29% 28% 27% 27% 26% 26% 25% 25% 25% 25% 25% 25% 25% 25% 25% 25%
35 32% 31% 30% 29% 28% 28% 27% 27% 27% 26% 26% 26% 26% 26% 26% 26% 26%
36 34% 32% 31% 31% 30% 29% 29% 28% 28% 28% 28% 28% 28% 28% 28% 28% 28%
37 36% 34% 33% 32% 31% 31% 30% 30% 30% 29% 29% 29% 29% 29% 29% 29% 29%
38 38% 36% 35% 34% 33% 33% 32% 32% 31% 31% 31% 31% 31% 31% 31% 31% 31%
39 40% 38% 37% 36% 35% 34% 34% 33% 33% 33% 33% 32% 32% 32% 32% 32% 32%
40 42% 41% 39% 38% 37% 36% 36% 35% 35% 35% 34% 34% 34% 34% 34% 34% 34%
41 45% 43% 42% 40% 39% 38% 38% 37% 37% 36% 36% 36% 36% 36% 36% 36% 36%
42 48% 46% 44% 43% 41% 40% 40% 39% 39% 38% 38% 38% 38% 38% 38% 38% 38%
43 50% 48% 47% 45% 44% 43% 42% 41% 41% 40% 40% 40% 40% 40% 40% 40% 40%
44 54% 51% 49% 48% 46% 45% 44% 43% 43% 43% 42% 42% 42% 42% 42% 42% 42%
45 57% 54% 52% 50% 49% 48% 47% 46% 45% 45% 44% 44% 44% 44% 44% 44% 44%

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 Policy Years/Term 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
46 60% 58% 55% 53% 52% 50% 49% 48% 48% 47% 47% 47% 46% 46% 46% 46% 46%
47 64% 61% 58% 56% 54% 53% 52% 51% 50% 49% 49% 49% 49% 49% 49% 49% 49%
48 68% 65% 62% 59% 57% 55% 54% 53% 52% 52% 51% 51% 51% 51% 51% 51% 51%
49 72% 68% 65% 62% 60% 58% 57% 56% 55% 54% 54% 53% 53% 53% 53% 53% 53%
50 77% 72% 69% 66% 63% 61% 60% 58% 57% 57% 56% 56% 56% 55% 55% 55% 55%
51 81% 77% 73% 69% 67% 64% 62% 61% 60% 59% 58% 58% 58% 58% 58% 58% 58%
52 87% 82% 77% 73% 70% 67% 65% 64% 62% 61% 61% 60% 60% 60% 60% 60% 60%
53 93% 87% 82% 77% 74% 71% 68% 66% 65% 64% 63% 63% 62% 62% 62% 62% 62%
54 100% 93% 87% 82% 78% 74% 71% 69% 68% 67% 66% 65% 65% 65% 65% 64% 64%
55 100% 93% 87% 82% 78% 75% 72% 71% 69% 68% 68% 67% 67% 67% 67% 67%
56 100% 93% 87% 82% 79% 76% 73% 72% 71% 70% 69% 69% 69% 69% 69%
57 100% 93% 87% 83% 79% 76% 75% 73% 72% 72% 71% 71% 71% 71%
58 100% 93% 87% 83% 80% 77% 76% 75% 74% 74% 73% 73% 73%
59 100% 93% 88% 83% 80% 78% 77% 76% 76% 75% 75% 75%
60 100% 93% 88% 84% 81% 80% 78% 78% 77% 77% 77%
61 100% 93% 88% 84% 82% 81% 80% 79% 79% 79%
62 100% 93% 88% 85% 83% 82% 81% 81% 81%
63 100% 93% 88% 86% 84% 83% 83% 82%
64 100% 93% 89% 86% 85% 84% 84%
65 100% 93% 89% 87% 85% 85%
66 100% 93% 89% 87% 86%
67 100% 93% 89% 87%
68 100% 93% 90%
69 100% 93%
70 100%

ANNEXURE- 1 Bhawani Singh Road, Jaipur – 302005 Tel : 0141-2740363 Email:

bimalokpal.jaipur@ecoi.co.in (State of Rajasthan) ERNAKULAM - Office
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN
of the Insurance Ombudsman, 2nd Floor, CC 27/2603, Pulinat Bldg., M.G.
CENTRES
Road, Ernakulam-682 015. Tel : 0484-2358759/2359338 Fax :
AHMEDABAD - Office of the Insurance Ombudsman, Jeevan Prakash 0484-2359336 Email: bimalokpal.ernakulam@ecoi.co.in [State of Kerala
Building, 6th Floor, Tilak Marg, Relief Road, Ahmedabad, 380001. Tel: and Union Territory of (a) Lakshadweep (b) Mahe-a part of Union Territory
079-25501201/02/05/06 Fax : 079-27546142 Email: of Pondicherry.] KOLKATA - Office of the Insurance Ombudsman,
bimalokpal.ahmedabad@cioins.co.in (State of Gujarat and Union Hindustan Building. Annexe, 4th Floor, C.R. Avenue, Kolkata-700 072. Tel
Territories of Dadra & Nagar Haveli and Daman and Diu.) BENGALURU - : 033-22124339/22124346 Fax : 033-22124341 Email:
Office of the Insurance Ombudsman, J24th Main Road, Jeevan Soudha bimalokpal.kolkata@ecoi.co.in (States of West Bengal, Bihar, Sikkim,
Bldg.,JP Nagar, 1st Phase, Ground Floor Bengaluru – 560 078. Tel.: Jharkhand and Union Territories of Andaman and Nicobar Islands.)
080-26652049/26652048Email: bimalokpal.bengaluru@ecoi.co.in. (State LUCKNOW- Office of the Insurance Ombudsman,Jeevan Bhawan,
of Karnataka) BHOPAL - Office of the Insurance Ombudsman, 2nd Floor, Phase-2, 6th Floor, Nawal Kishore Road, Hazaratganj, Lucknow-226 001.
Janak Vihar Complex, 6, Malviya Nagar, Bhopal(M.P.)-462 003. Tel.:- Tel : 0522 -2231331/2231330 Fax : 0522-2231310 Email:
0755-2769201/9202 Fax : 0755-2769203 Email: bimalokpal.lucknow@ecoi.co.in (States of Uttar Pradesh and Uttaranchal.)
bimalokpal.bhopal@ecoi.co.in (States of Madhya Pradesh and MUMBAI - Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva
Chattisgarh.) BHUBANESHWAR - Office of the Insurance Ombudsman, Annexe, S.V. Road, Santacruz(W), Mumbai 400054. Tel :
62, Forest Park, Bhubaneshwar-751 009. Tel.:- 0674-2596455/2596003 022-26106960/26106552 Fax : 022-26106052 Email:
Fax : 0674-2596429 Email: bimalokpal.bhubaneswar@ecoi.co.in (State of bimalokpal.mumbai@ecoi.co.in (State of Goa and Mumbai Metropolitan
Orissa.) CHANDIGARH - Office of the Insurance Ombudsman, S.C.O. Region excluding Navi Mumbai and Thane) PUNE - Office of the Insurance
No.101-103,2nd Floor, Batra Building, Sector 17-D, Chandigarh-160017. Ombudsman,3rd Floor, Jeevan Darshan Bldg,N.C. Kelkar
Tel.:- 0172-2706468/2772101 Fax : 0172-2708274 Road,Narayanpet, Pune – 411030. Tel: 020-41312555Email:
Email:bimalokpal.chandigarh@ecoi.co.in (States of Punjab, Haryana, bimalokpal.pune@ecoi.co.in (State of Maharashtra including Navi Mumbai
Himachal Pradesh, Jammu & Kashmir and Union territory of Chandigarh.) and Thane and excluding Mumbai Metropolitan Region.) NOIDA - Office of
CHENNAI- Office of the Insurance Ombudsman, Fathima Akhtar Court, the Insurance Ombudsman,4th Floor, Bhagwan Sahai Palace,Main Road,
4th Floor, 453 (old 312), Anna Salai, Teynampet, Chennai-600 018.Tel.:- Naya Bans, Sector-15,Noida - 201301.Tel: 0120-2514250/51/53Email:
044-24333668 /24335284 Fax : 044-24333664 Email: bimalokpal.noida@ecoi.co.in (State of Uttaranchal and the following
bimalokpal.chennai@ecoi.co.in [State of Tamil Nadu and Union Territories - Districts of Uttar Pradesh:Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
Pondicherry Town and Karaikal (which are part of Union Territory of Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad,
Pondicherry).] DELHI- Office of the Insurance Ombudsman, 2/2 A, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad,
Universal Insurance Building., Asaf Ali Road, New Delhi-110 002. Tel.:- Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli,
011-011-23234057/23232037 Fax : 011-23230858 Email: Rampur, Kashganj, Sambhal, Amroha, Hathras, Kanshiramnagar,
bimalokpal.delhi@ecoi.co.in (States of Delhi) GUWAHATI - Office of the Saharanpur.) PATNA - Office of the Insurance Ombudsman, 1st Floor,
Insurance Ombudsman, “Jeevan Nivesh”, 5th Floor, S.S. Road, Kalpana Arcade Building, Bazar Samiti Road, Bahadurpur, Patna –
Guwahati-781 001 Tel.:- 0361-2132204/5 Fax : 0361-2732937 Email: 800006, Tel No: 06122680952, Email id :
bimalokpal.guwahati@ecoi.co.in (States of Assam, Meghalaya, Manipur, bimalokpal.patna@ecoi.co.in.(Bihar, Jharkhand.)
Mizoram, Arunachal Pradesh, Nagaland and Tripura.) HYDERABAD -
For further information or latest updated list of Ombudsman Office
Office of the Insurance Ombudsman, 6-2-46, 1st Floor, Moin Court, A.C. addresses, kindly visit the IRDAI website http://www.Policyholder.gov.in/ -
Guards, Lakdi-Ka-Pool, Hyderabad-500 004. Tel : Ombudsman / List of Insurance Ombudsmen OR our website
040-65504123/23312122 Fax: 040-23376599 Email: www.tataaia.com
bimalokpal.hyderabad@ecoi.co.in (States of Andhra Pradesh and Union
Territory of Yanam – a part of the Union Territory of Pondicherry.) JAIPUR-
Office of the Insurance Ombudsman, Ground Floor, Jeevan Nidhi II,

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 ANNEXURE 2 and
A. Section 38 - Assignment and Transfer of Insurance Policies b. may institute any proceedings in relation to the Policy
Assignment or transfer of a Policy should be in accordance with Section c. obtain loan under the Policy or surrender the Policy without
38 of the Insurance Act, 1938 as amended by Insurance Laws obtaining the consent of the transferor or assignor or making him
a party to the proceedings
(Amendment) Act, 2015.The extant provisions in this regard are as follows:
15. Any rights and remedies of an assignee or transferee of a life Insurance
01. This Policy may be transferred/assigned, wholly or in part, with or
Policy under an assignment or transfer effected before
without consideration. commencement of the Insurance Laws (Amendment) Act, 2015 shall
02. An Assignment may be effected in a Policy by an endorsement upon not be affected by this section.
the Policy itself or by a separate instrument under notice to the Insurer. [Disclaimer: This is not a comprehensive list of amendments of Insurance
03. The instrument of assignment should indicate the fact of transfer or Laws (Amendment) Act, 2015 and only a simplified version prepared for
assignment and the reasons for the assignment or transfer, general information. Policyholders are advised to refer to Insurance Laws
antecedents of the assignee and terms on which assignment is made. (Amendment) Act, 2015 for complete and accurate details. ]
04. The assignment must be signed by the transferor or assignor or duly ANNEXURE 3
authorized agent and attested by at least one witness. B. Section 39 - Nomination by Policyholder
05. The transfer of assignment shall not be operative as against an insurer
Nomination of a life Insurance Policy is as below in accordance with
until a notice in writing of the transfer or assignment and either the said Section 39 of the Insurance Act, 1938 as amended by Insurance Laws
endorsement or instrument itself or copy there of certified to be correct (Amendment) Act, 2015. The extant provisions in this regard are as follows:
by both transferor and transferee or their duly authorised agents have
01. The Policyholder of a life Insurance on his own life may nominate a
been delivered to the insurer.
person or persons to whom money secured by the Policy shall be paid
06. Fee to be paid for assignment or transfer can be specified by the in the event of his death.
Authority through Regulations. 02. Where the nominee is a minor, the Policyholder may appoint any
07. On receipt of notice with fee, the insurer should Grant a written person to receive the money secured by the Policy in the event of
acknowledgement of receipt of notice. Such notice shall be conclusive Policyholder’s death during the minority of the nominee. The manner of
evidence against the insurer of duly receiving the notice. appointment to be laid down by the insurer.
08. If the insurer maintains one or more places of business, such notices 03. Nomination can be made at any time before the maturity of the Policy.
shall be delivered only at the place where the Policy is being serviced. 04. Nomination may be incorporated in the text of the Policy itself or may
09. The insurer may accept or decline to act upon any transfer or be endorsed on the Policy communicated to the insurer and can be
registered by the insurer in the records relating to the Policy.
assignment or endorsement, if it has sufficient reasons to believe that
it is 05. Nomination can be cancelled or changed at any time before Policy
matures, by an endorsement or a further endorsement or a will as the
a. not bonafide or case may be.
b. not in the interest of the Policyholder or 06. A notice in writing of Change or Cancellation of nomination must be
c. not in public interest or delivered to the insurer for the insurer to be liable to such nominee.
Otherwise, insurer will not be liable if a bonafide payment is made to
d. is for the purpose of trading of the Insurance Policy.
the person named in the text of the Policy or in the registered records
10. Before refusing to act upon endorsement, the Insurer should record of the insurer.
the reasons in writing and communicate the same in writing to 07. Fee to be paid to the insurer for registering change or cancellation of a
Policyholder within 30 days from the date of Policyholder giving a nomination can be specified by the Authority through Regulations.
notice of transfer or assignment.
08. On receipt of notice with fee, the insurer should grant a written
11. In case of refusal to act upon the endorsement by the Insurer, any acknowledgement to the Policyholder of having registered a
person aggrieved by the refusal may prefer a claim to IRDAI within 30 nomination or cancellation or change thereof.
days of receipt of the refusal letter from the Insurer. 09. A transfer or assignment made in accordance with Section 38 shall
12. The priority of claims of persons interested in an Insurance Policy automatically cancel the nomination except in case of assignment to
would depend on the date on which the notices of assignment or the insurer or other transferee or assignee for purpose of loan or
transfer is delivered to the insurer; where there are more than one against security or its reassignment after repayment. In such case, the
instruments of transfer or assignment, the priority will depend on dates nomination will not get cancelled to the extent of insurer’s or
of delivery of such notices. Any dispute in this regard as to priority transferee’s or assignee’s interest in the Policy. The nomination will get
should be referred to Authority. revived on repayment of the loan.
13. Every assignment or transfer shall be deemed to be absolute 10. The right of any creditor to be paid out of the proceeds of any Policy of
assignment or transfer and the assignee or transferee shall be deemed life Insurance shall not be affected by the nomination.
to be absolute assignee or transferee, except 11. In case of nomination by Policyholder whose life is insured, if the
a. where assignment or transfer is subject to terms and conditions of nominees die before the Policyholder, the proceeds are payable to
transfer or assignment OR Policyholder or his heirs or legal representatives or holder of
succession certificate.
b. where the transfer or assignment is made upon condition that
12. In case nominee(s) survive the person whose life is insured, the
i. the proceeds under the Policy shall become payable to amount secured by the Policy shall be paid to such survivor(s).
Policyholder or nominee(s) in the event of assignee or transferee
dying before the Life Assured OR 13. Where the Policyholder whose life is Life Assured nominates his
ii. the Life Assured surviving the term of the Policy a. parents or
Such conditional assignee will not be entitled to obtain a loan on Policy b. spouse or
or surrender the Policy. This provision will prevail notwithstanding any c. children or
law or custom having force of law which is contrary to the above d. spouse and children
position.
e. or any of them
14. In other cases, the insurer shall, subject to terms and conditions of
assignment, recognize the transferee or assignee named in the notice the nominees are beneficially entitled to the amount payable by the
as the absolute transferee or assignee and such person insurer to the Policyholder unless it is proved that Policyholder could
not have conferred such beneficial title on the nominee having regard
a. shall be subject to all liabilities and equities to which the transferor to the nature of his title.
or assignor was subject to at the date of transfer or assignment
14. If nominee(s) die after the Policyholder but before his share of the

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 amount secured under the Policy is paid, the share of the expired ground that any statement of or suppression of a fact material to
nominee(s) shall be payable to the heirs or legal representative of the expectancy of life of the Life Assured was incorrectly made in the
nominee or holder of succession certificate of such nominee(s). proposal or other document basis which Policy was issued or revived
15. The provisions of sub-section 7 and 8 (13 and 14 above) shall apply to or rider issued. For this, the insurer should communicate in writing to
all life Insurance policies maturing for payment after the the Life Assured or legal representative or nominee or assignees of
commencement of Insurance Laws (Amendment) Act, 2015. insured, as applicable, mentioning the ground and materials on which
decision to repudiate the Policy of life Insurance is based.
16. If Policyholder dies after maturity but the proceeds and benefit of the
Policy has not been paid to him because of his death, his nominee(s) 07. In case repudiation is on ground of mis-statement and not on fraud,
shall be entitled to the proceeds and benefit of the Policy. the premium collected on Policy till the date of repudiation shall be
paid to the Life Assured or legal representative or nominee or
17. The provisions of Section 39 are not applicable to any life Insurance assignees of insured, within a period of 90 days from the date of
Policy to which Section 6 of Married Women’s Property Act, 1874 repudiation.
applies or has at any time applied except where before or after
Insurance Laws (Amendment) Act, 2015., a nomination is made in 08. Fact shall not be considered material unless it has a direct bearing on
favour of spouse or children or spouse and children whether or not on the risk undertaken by the insurer. The onus is on insurer to show that
the face of the Policy it is mentioned that it is made under Section 39. if the insurer had been aware of the said fact, no life Insurance Policy
Where nomination is intended to be made to spouse or children or would have been issued to the insured.
spouse and children under Section 6 of MWP Act, it should be 09. The insurer can call for proof of age at any time if he is entitled to do so
specifically mentioned on the Policy. In such a case only, the provisions and no Policy shall be deemed to be called in question merely because
of Section 39 will not apply. the terms of the Policy are adjusted on subsequent proof of age of Life
[Disclaimer: This is not a comprehensive list of amendments of Insurance Insured. So, this Section will not be applicable for questioning age or
Laws (Amendment) Act, 2015 and only a simplified version prepared for adjustment based on proof of age submitted subsequently.
general information. Policyholders are advised to refer to Insurance Laws [Disclaimer: This is not a comprehensive list of amendments of Insurance
(Amendment) Act, 2015 for complete and accurate details. ] Laws (Amendment) Act, 2015. and only a simplified version prepared for
general information. Policyholders are advised to refer to Insurance Laws
ANNEXURE 4 (Amendment) Act, 2015 for complete and accurate details.]
C. Section 45 – Policy shall not be called in question on the ground
of mis-statement after three years
Provisions regarding Policy not being called into question in terms of
Section 45 of the Insurance Act, 1938, as amended by Insurance Laws
(Amendment) Act, 2015 are as follows:
01. No Policy of Life Insurance shall be called in question on any ground
whatsoever after expiry of 3 yrs from
a. the date of issuance of Policy or
b. the date of commencement of risk or
c. the date of revival of Policy or
d. the date of rider to the Policy
whichever is later.
02. On the ground of fraud, a Policy of Life Insurance may be called in
question within 3 years from
a. the date of issuance of Policy or
b. the date of commencement of risk or
c. the date of revival of Policy or
d. the date of rider to the Policy
whichever is later.
For this, the insurer should communicate in writing to the Life Assured
or legal representative or nominee or assignees of insured, as
applicable, mentioning the ground and materials on which such
decision is based.
03. Fraud means any of the following acts committed by Life Assured or
by his agent, with the intent to deceive the insurer or to induce the
insurer to issue a life Insurance Policy:
a. The suggestion, as a fact of that which is not true and which the
Life Assured does not believe to be true;
b. The active concealment of a fact by the Life Assured having
knowledge or belief of the fact;
c. Any other act fitted to deceive; and
d. Any such act or omission as the law specifically declares to be
fraudulent.
04. Mere silence is not fraud unless, depending on circumstances of the
case, it is the duty of the Life Assured or his agent keeping silence to
speak or silence is in itself equivalent to speak.
05. No Insurer shall repudiate a life Insurance Policy on the ground of
Fraud, if the Life Assured/ beneficiary can prove that the misstatement
was true to the best of his knowledge and there was no deliberate
intention to suppress the fact or that such mis-statement of or
suppression of material fact are within the knowledge of the insurer.
Onus of disproving is upon the Policyholder, if alive, or beneficiaries.
06. Life Insurance Policy can be called in question within 3 years on the

Tata AIA Life Insurance Sampoorna Raksha Supreme (UIN: 110N160V02) • IRDA of India Regn no. 110

C2021-05
 CLAIM DOCUMENT LIST

Requirements for Hospitalization & Critical Requirements for Disability and Requirements for Death Claim (all causes of
Illness Claim Dismemberment Claim Death)
A Claim Forms A Claim Forms A Claim Forms
Part I: Application Form for Hospitalization/Critical Part I: Application Form for Part I: Application Form for Death Claim
Illness Claim (Claimant's Statement) along with Disability/Dismemberment Claim (Claimant's (Claimant's Statement) along with NEFT form
NEFT form Statement) along with NEFT form Part II:Physician's Statement - to be filled by last
Part II: Confidential Medical Report -to be filled by Part II: Confidential Medical Report -to be filled by attending physician
attending physician attending physician

B Hospital Bills for the confinement. B Attested True Copy of Indoor Case Papers of the B Death Certificate issued by a local government
Hospital body like Municipal Corporation
C Attested True Copy of Indoor Case Papers of the C Discharge Summary of Present and Past C Medical Records (Admission Notes,
Hospital Hospitalizations Discharge/Death Summary, Indoor Case Papers,
Test Reports etc)1

D Discharge Summary of Present and Past D Photo Identity of insured with age and address D Original Policy document
Hospitalizations proof

E Photo Identity of insured with age and address E Bank Details of the claimant – Cancelled cheque E Claimant's Photo ID with age proof & relationship
proof (with printed name and account number)/bank with the Insured along with Address proof of the
passbook and NEFT Form claimant and Cancelled cheque with name and
account number printed or cancelled cheque with
copy of Bank Passbook / Bank Statement

If no nomination - Proof of legal title to the claim

proceeds (e.g. legal succession paper)

F Bank Details of the claimant – Cancelled cheque F Disability Certificate by attending Physician /
(with printed name and account number)/bank Institute for disabled
passbook and NEFT Form
G Certificate of Diagnosis G Rehabilitation Certificate - if applicable

H Medical Examination Certificate (First H Employer’s written confirmation / statement - for

Consultation Notes). Disability claim

I All related clinical Reports pertaining to the claim I All related Medical Examination Reports, e.g. -
event - Laboratory test reports
Laboratory test reports X-Ray / CT Scan / MRI Reports & Plates
X-Ray / CT Scan / MRI Reports & Ultrasonography Report
PlatesUltrasonography Report Clinical / Hospital Reports
Histopathology Report
Clinical / Hospital Reports
Angiography Reports & Plates.
Others (please specify).
J All follow-up Consultation Notes in relation to the J Clinical Photographs showing the injured areas -
hospitalized condition. if available
If Claims is due to accidental causes (submit in If Claims is due to accidental causes (submit in In case of accidental death inaddition to the above
addition to the above) addition to the above). documents, we would require the following
documents –
K All police reports- K All police reports- F Postmortem report (Autopsy report) &
First Information Report First Information Report Chemical Viscera report - if performed
Final Investigation Report Final Investigation Report
G All Police Papers – Panchnama, Inquest, First
Information Report (FIR) and Final Investigation
Report
H Newspaper cutting / Photographs of the accident -
if available

1. This is applicable if insured was in hospital at the time of death or any time prior to the date of death.
• Please submit copies of the following documents certified / attested by the issuing authority. ( Original Seen Verified (OSV) by Branch Personnel will also be accepted) -
o All Police papers – Panchnama, Inquest, First Information Report and Final Investigation Report
o Medical Records (Admission Notes, Discharge/Death Summary, Indoor Case Papers, Test Reports etc)1
o Postmortem report (Autopsy report) & Chemical Viscera report (certified by Police / Magistrate / Court will also be accepted)
• Copies of the other documents to be submitted by self attestation of the claimant

NOTE:
- In case the claim warrants any additional requirement, TATA AIA LIFE reserves the right to call for the same.
- Notification of claim & submission of the claim requirements does not mean admission of the claim liability by the Company.
- No agent is authorized to admit any liabilities on behalf of the Company, nor to alter this list of documents or any claims requirements called for by the Company.
 FREQUENTLY ASKED QUESTIONS (FAQs)

1. How can I cancel my policy under Free Look?

 The policy can be cancelled anytime within 15 days from the date of receipt of the
policy document. Kindly submit the policy document along with a duly signed letter at any of the
Tata AIA Life branches#.

2. How can I change the premium payment mode?

 Please submit a duly signed copy of the Mode change form* at any of the Tata AIA Life
branches# at least 10 days before the due date of the policy.
 Please contact the branch or call center for mode changes allowed on your policy

3. How can I make the below mentioned changes in my policy?

- Name change - Address / Contact Number Change
- Ownership Change - Signature Change
- Nominee Change - Basic Plan Change
 Please submit a duly signed copy of the respective change form* along with the documents
mentioned in the form at any of the Tata AIA Life branches#.

4. Can I opt for automatic premium payment facility on my policy?

 You can avail of any of the following facilities wherein your account / Credit Card will be
debited on the due date of your policy.
o ECS - A signed copy of the ECS form* along with a cancelled cheque or copy of cancelled
cheque needs to be submitted at any of the Tata AIA Life branches at least 10 days prior to the
due date
o Credit Card – A signed copy of the Credit Card form* along with a copy of Front page of
credit card needs to be submitted at any of the Tata AIA Life branches at least 10 days prior to the
due date
o Direct debit – You can avail of Direct Debit facility by providing a copy of an 'ECS &
Direct Debit' form* with copy of cancelled cheque or bank attestation at least 30 days before the
due date. To know the list of banks wherein this facility is available, kindly visit the 'Premium
Payment Options' on www.tataaia.com.

5. I have lost my PIP and need a duplicate PIP.

 Please submit a duly signed copy of the Duplicate PIP form* along with the documents
mentioned in the form at any of the Tata AIA Life branches#.

6. How can I view my policy related details online?

 You can create your online account by logging in to www.tataaia.com and avail of the
following benefits –
o Easy access to policy related details (Premium Due Date, NAV, Payment Summary, etc.,)
o Single access for all your policies
o Perform Online ULIP transactions
o Pay Premium Online
o Generate e-statements (Premium Certificates, Unit Statements)
o Raise Service Requests

7. How do I request for a Premium Payment Certificate for my policies?

 You can request for your Premium Certificate through the following modes -
o Online Customer Portal - Kindly logon to your Online Account by visiting
www.tataaia.com
o SMS - Kindly SMS the following to 5676799:
  PCT <space> 10 digit policy no <space> email address (in case you wish to receive by
email, else will be sent to your communication address) <space> financial year (yyyy-yyyy
format)
 The mobile number from where the SMS has been sent should be registered with the
company. In case your mobile number is not registered, please send the following SMS to
5676799:
REG <space> 10 digit policy no <space> Insured's DOB in DDMMYYYY format <space>
Sum Assured
(For Health, Annuity and Pension plans, Sum Assured should be mentioned as '0')
o Email / Call / Branch - Request for the Premium Certificate by sending an email to
customercare@tataaia.com or call our helpline number at 1-860-266-9966 (local charges apply)
or visit the nearest branch#.

8. For my unit linked policy, how can I request for Fund Switch, Premium Redirection & Top-up?
 You can create your online account by logging in to www.tataaia.com and perform Fund
Switch, Premium Redirection and Top-up transactions instantly (or)
 Please submit a duly signed copy of the Fund Allocation, Switch & Top-up form* pertaining
to your product at any of the Tata AIA Life branches#.

* You can download the forms by visiting 'Customer Services' section on www.tataaia.com
#
For your nearest Tata AIA Life branch, please visit 'Contact Us' section on www.tataaia.com.

You can also send the forms along with the documents to the below mentioned address –
Policy Owners Services
Tata AIA Life Insurance Company Limited,
B-Wing, 9th Floor, I-Think Techno Campus,
Behind TCS, Pokhran Road No.2,
Close to Eastern Express Highway,
Thane (West) – 400 607, Maharashtra
PROPOSAL FORM
 Medical Examination Report
Transcript of the Videotelephony Medical Examination Report
This is the transcript of the answers provided by Life to be assured verbally to the questions asked below in a videotelephony verification by the
underwriting team of Tata AIA Life Insurance Company Ltd. The answers provided by the Life to be assured would form a part of the application for
insurance.
We request you to go through the transcript carefully. In case of any disagreement, you are requested to highlight the same within 15 days of the
receipt of this transcript; otherwise this would be taken as acceptable to you and thereby binding on you. Please retain this transcript for future
reference.

Application No. C230378803 Date 07-Oct-2021

Life to be Assured (LA) Mr AKSHAY MOGHE Contact No. 9527071900

Date of Birth 08-Oct-1987 Gender MALE

ID Details ARDPM5034G BMI 29.3

These are the following questions, along with their answers, that were asked during the examination:
YES NO IF YES, please give details

1 Kindly confirm your full Name Yes AKSHAY MOGHE

2 Your Date of birth Yes 8 oct 1987

Occupation

- Salaried
3 Your current Occupation Yes
Others

- IT professional

4 Your annual income Yes 1347824

5 Please show your ID proof Yes driving license

6 Are you currently in Good Health ? Yes

7 Are you taking any type of medication currently? No

8 Weight Yes 90

9 Height Yes 175.26

Have you lost or gained weight of 10 kg or more in the last six

10 No
months?

Have you ever in the past consumed or currently consume tobacco

11 No
in any form like Cigarette,Bidi,Pan,Gutkha?

12 Have you ever in the past or are currently consuming Alcohol? No

13 Have you ever in the past or are currently consuming Narcotics? No

Have you ever been diagnosed and treated for any of following
14 conditions or are currently being treated or underwent surgery for No
Diabetes,high blood sugar

Have you ever been diagnosed and treated for any of following
15 conditions or are currently being treated or underwent surgery for No
High blood pressure,Hypertension ,Elevated Cholesterol,Lipids?

16 Have you ever been diagnosed and treated for any of following No
conditions or are currently being treated or underwent surgery for
 Chest pain, heart attack, palpitation, any other heart disease or
circulatory disease?

Exact Diagnosis

- Others (please specify)

Date of Diagnosis or Duration of disorder

- 28 dec 2020, Anal fissure

Have you ever been diagnosed and treated for any of following
conditions or are currently being treated or underwent surgery for Treatment details
17 Yes
Any lung,respiratory Disease or Urine,Kidney disease or any Liver
- Medication
,gastric disorders?
Remarks

- hard stools, pain during defecation, in dec 2020,

medicine duflex for 15 days, anobliss ointment for 10
days and others, sitz bath with warm water for 5 day, no
recurrence , never consulted after that

Have you ever been diagnosed and treated for any of following
18 conditions or are currently being treated or underwent surgery for No
Cancer or tumor of any kind?

Do you or your spouse has been tested positive or is under

19 treatment for HIV , AIDS or Sexually transmitted diseases (e.g. No
syphilis, gonorrhea, etc.)?

Have you ever been diagnosed and treated for any of following
20 conditions or are currently being treated or underwent surgery for No
Any Accidental injury,Disability?

Exact Diagnosis

- Others (Please specify)

Date of Diagnosis or Duration of disorder

- 2 - 3 months back
Do you have any other health condition or are you currently/in
21 past were under any treatment for any health condition not Yes Treatment details
covered above?
- Medication

Remarks

- pain in testicles after sexual inter-coarse, medicine 3

days

22 Have you undergone any investigations like blood ,urine test , X- Yes
ray , ECG or any special test such as TMT, CT scan, MRI? Reason for undergoing test

- Diagnosis/Treatment/Follow up/Any other

Results of the test

- Normal

Past Surgery

- Any other furnish details

Remarks

- CBC,CRP in nov 2020 after covid-19 positive

Reason for undergoing test

- Annual health checkp

Results of the test

 - Normal

Past Surgery

- Any other furnish details

Remarks

- full body body checkup

Have you ever been hospitalized for any illness, sickness, disease,
23 No
injury, accident or disorder in the last 5 years?

Relation

- Father

Exact diagnosis

- Heart disease

Positive family history

- 1 first degree relative

Have either of your natural parents or any siblings suffered from
24 or are suffering from any medical condition like Cancer, Heart Yes Diagnosed before age 50 yrs
related Problems, Diabetes, Blood Pressure, Hepatitis etc.?
- No

Currently alive

- No

Remarks

- Dec 2020, died due acute coronary syndrome post

covid-19 positive, hospitalized for desaturation and stroke

Has any of your insurance application or reinstatement

application on life, accident, medical or health, critical illness, or
25 No
disability ever been declined, postponed or accepted at extra
premium or modified terms?

[For Male]Have you ever been diagnosed &/OR treated for

26 Prostate related disorder or been under follow up for the same No
with PSA test, USG pelvis etc.

27 [For Female] Are you currently pregnant ? No

[For Female] Have you undergone any gynaecological

28 investigations for any problems of breast , uterus , cervix etc.Have No
you done or advised for any Pap smear, mammogram?

[For Female] Have you ever consulted a doctor because of an

irregularity at the breast, vagina, uterus, ovary, fallopian tubes,
29 No
menstruation, complications during pregnancy or child delivery or
a sexually transmitted disease?

13 nov 2020 covid-19 report positive along with family,

home isolation for 17 days, medication (Zinc,VitC for 5
30 Have you ever been tested positive for coronavirus (COVID-19)? Yes days), investigated with blood test are normal, negative
report (RT-PCR) done 2 months back, no hospitalization,
no complication

Have you ever self-isolated/quarantined due to symptoms of during covid-19 positive in nov 2020, home isolated for
31 Yes
coronavirus (COVID-19)? 17 days

32 Have you been vaccinated for COVID19? Yes

When was vaccination done?

- > 1 month

Have both doses been completed?

- Yes
 Have you experienced any adverse reaction post-
vaccination?

- No

Date of Vaccination

- 2nd dose - 26 august 2021

Remarks

- covisheild

- Existing Health history other than mentioned above

Exact Diagnosis

- dental issue

Date of Diagnosis/Duration of disorder

- 17 sep 2021

Treatment details

- medication
Is there anything else that you would like to share with us with
respect to your health,habits or anything else that you believe is Current health status
33 Yes
important to ensure that policy is processed basis all facts &
information? - Normal

Availability of reports

- NA

Next follow up

- NA

Remarks

- dental checkup, scaling done, advised mouth wash and

metrogyl Dg fort for 15 days

DECLARATION:

You AKSHAY MOGHE, declare that, you have fully understood the questions asked to you as per this call and have furnished complete, true and accurate
information after fully understanding the same.

Sir/Mam' are you in agreement with the declaration that I have read out to you.

We thank you for having taken the time to confirm the details. We will process your proposal based on the information provided.

Name and Signature of the Medical Doctor/ Medical Underwriter

Dr. Shiv Kumar Garg

Reg no: 36876

Dated Time of Medical Verification 07/10/2021 20:59

Tata AIA Life Insurance Company Limited.
COMMON PROPOSAL FORM

Kindly Fill the form in CAPITAL and only in blue or black

(For Official Use only)

Proposal Number: C230378803 Branch Code:

Channel: BROKING Campaign Code:

Sub Office Code: NJI0011 RM CAMS Code: 4618634

Agent/Broker/Specified Person/Employee: NJ Insurance Brokers Pvt Ltd

Code: 4503123 Contact Details: License No. & Validity Details:

Customer Relationship No. (For Bancassurance Channel) PAN No.

IMPORTANT GUIDELINES: 1) IN UNIT-LINKED INSURANCE POLICIES (ULIPs), THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER. 2)
Insurance is a contract of utmost good faith between the Insurer and the Insured. The Proposer and the Life to be Assured are required to disclose all facts in response to the
questions in this application form. 3) Any cancellation/alteration is to be signed by Proposer/Life to be assured as applicable. 4) KYC documents will be required for all the parties to the
contract.

I. GENERIC DETAILS

Is this policy self-proposed? Yes. If No, please answer the following details Type of Proposer: Individual Life

Relation with Life Assured: Self Type of Proposal:

II. ELECTRONIC INSURANCE ACCOUNT (eIA) DETAILS OF THE PROPOSER/POLICYOWNER

If you have an e-Insurance Account (eIA) Number, please provide:

I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Tata AIA Life Insurance Company Ltd. In Electronic format
(Physical copy would be sent even if proposer opts for electronic format; however, in case proposer has e-Insurance Account, only electronic copy of the Insurance Policy will be
provided)
I would like to receive my Insurance Policy and all the information related to the proposed Insurance Policy through Insurance Repository in the Electronic Format as and when
applicable. Please select the name of the Insurance Repository.
NSDL

III. PRODUCT DETAILS

Unit Sum Premium Premium ( ) (Inclusive of Premium Return of

Base Plan/ Rider (Benefit Policy
Linked Life Insured Name Assured Paying applicable taxes, cesses & Paying Premium
Option) Name Term(Years)
(Yes/No) ( ) Term(Years) levies ) Mode option

Tata AIA Life Insurance

No Mr. AKSHAY MOGHE 10000000 38 38 15576 Annual NA
Sampoorna Raksha Supreme

Life Insured Details Benefit Payout Option Details

Rider (Benefit Option)
Benefit Payout Option
Name Lumpsum ( Income p.a ( Income Income
Name DOB Gender
) ) Duration(Years) Frequency

Kindly DATE BACK my Application to 1. Allowed only as per product specifications 2. Allowed within the same financial year 3. In case of juvenile (less than 1 year) back date is not
allowed. 4. Date Back of policy is allowed only up to the official launch date of the product.
FUND SELECTION DETAILS (To be filled for Unit Linked Products) a. Kindly mention the names of the fund chosen b. Incase you opt for a specific Portfolio Strategy (as available
with individual products), kindly mention the Fund Names or other details as applicable c. Kindly fill in whole numbers in percentage only. Decimals and Fractions not allowed.

Portfolio Strategy

Name of Fund % Allocation

 Name of Fund % Allocation
Funds for the chosen Portfolio Strategy (If Applicable )
OR
Debt oriented fund Equity oriented fund

Other Details(if applicable)

IV. PROPOSER / POLICYHOLDER DETAILS (Please fill in details of Life Assured if same as Proposer)

1. Title Mr.

2. Name AKSHAY MOGHE

3. Father's Name / Spouse Name PRAMOD VASUDEO MOGHE

4. Mother's Name SNEHAL MOGHE

5. Maiden Name(For female lives only)

6. Gender/Date of Birth Male 08-10-1987

7. Which is your Dominant Hand? (Question to be answered only if ADDL

Rider is selected )

8. Marital Status Married

Resident Indian (Nationality) INDIA

Country of Residence : INDIA
9. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
(If country of residence or nationality outside India then FATCA/ CRS-Self Certification Form to be
mandatorily completed)

Residence for Tax purposes in Jurisdiction(s) outside India No (If Yes then FATCA/ CRS-Self Certification Form to be mandatorily completed)

10. Highest Educational Qualification Graduate

V N RAO HOUSE BEHIND OLD NOVA OFFICE WARD NO-03 H,NO-1355, MAHAMAYA VIHAR WARE
HOUSE ROAD
11. Current Residence Address
Landmark: LANE R2 City: BILASPUR

State: CHHATTISGARH Country: INDIA Pin code: 495001

S/O PRAMOD V MOGHE FLAT NO A-202 GALORE PARK SURVEY NO 22 BEHIND MARATHA MANDIR
BAVDHAN KHURD
12. Permanent Address
Landmark: OPP HP PETROL PUMP City: PUNE

State: MAHARASHTRA Country: INDIA Pin code: 411021

13. Address for Communication Current

Residence No: Mobile No: 9527071900

14. Telephone and Email Details
E-mail: MOGHEAKSHAY@GMAIL.COM

15. Occupation Class Salaried

a. Name of Organisation /School / College Tata Consultancy Services Limited

b. Organisation Type Public Limited

c. Industry Information Technology

d. Nature of Work Information Analyst

e. Annual Income ( ) 1347824

16. Income Proof

17. Identity Proof (In case of Passport & Driving License please mention expiry PAN Card Expiry Date :
date) ARDPM5034G

18. Address Proof (Utility bills should not be older than 2 months) Aadhar card, UID

ARDPM5034G (kindly attach copy of Pan card)

19. Permanent Account Number ( PAN ) :
Yes I do not have PAN (kindly attach copy of Form 60 duly signed)

20. CKYC No. (If available)

21. Source of Funds

22. Are you a Politically Exposed Person? No. (Definition of PEP: "PEP are individuals who are or have been entrusted with prominent public functions, domestically/in an international organisation /in a foreign
country. This would include individuals who have or have had positions of Heads of State or of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations,
important political party officials". "Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of partnership. Close
associates are individuals closely connected to a PEP, either socially or professionally")

V. LIFE ASSURED DETAILS (Please fill in this section only if Life Assured is different from Proposer)

1. Title

2. Name

3. Maiden Name(For female lives only)

4. Gender/Date of Birth

5. Which is your Dominant Hand? (Question to be answered only if ADDL

Rider is selected )

6. Marital Status

(Nationality)
7. Nationality (If other than resident Indian, Passport as an age proof is mandatory)
Country of Residence
8. Highest Educational Qualification

9. Occupation Class

10. Name of Organisation/ School/College

11. Organisation Type

12. Industry

13. Nature of Work

14. Annual Income ( )

15. Income Proof

16. Identity Proof (In case of Passport & Driving License please mention expiry Expiry Date :
date) Others :

17. Address Proof (Utility bills should not be older than 2 months)

(kindly attach copy of Pan card)

18. Permanent Account Number (PAN):
Yes I do not have PAN (kindly attach copy of Form 60 duly signed)

19. Are you a Politically Exposed Person? (Definition of PEP: PEP are individuals who are or have been entrusted with prominent public functions, domestically/in an international organisation /in a foreign country.
This would include individuals who have or have had positions of Heads of State or of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations,
important political party officials. Close relations of PEP: Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of partnership. Close associates
are individuals closely connected to a PEP, either socially or professionally)

VI. HEALTH & LIFESTYLE DETAILS OF THE LIFE ASSURED

1. Nature of Age proof (Non-standard age proof submission will attract extra premium)
PAN Card

2. a) Height (cms or ft) b) Weight ( kg or lbs). 175 cms 90 kgs

PART A: LIFESTYLE DETAILS

1. Are you employed in the Armed Forces, Paramilitary, Police Forces, Fire Brigade or any other similar occupation? No

2. Is your occupation/your hobbies associated with any specific accident/health hazard or are dangerous in any way (e.g. working with dangerous or corrosive chemicals,
explosives, radiation, working underwater/underground or at height, working in mines, non-commercial flying activities, diving, mountaineering, any form of motorbike/car racing No
etc.)?

3. Do you intend to live or travel outside India for more than 30 days for reason other than family vacation in next 6 months? No

4. Have you ever been charge sheeted or convicted of any criminal proceedings or have any criminal case or charge pending against you in any court of law in India or abroad? If
Yes, please provide complete details. No

5. Do you consume or have consumed any of the following? Please tick all relevant options and provide details No

Substance Yes/ Consumed Quantity/ Per Day for Tobacco & Per week for Alcohol No. of If stopped consumption, mention month and year in which
Consumed No As and Narcotics Years last consumed

Tobacco No

Alcohol No

Any Narcotics No

PART B: HEALTH & PERSONAL DETAILS

1. Has any of your insurance application or reinstatement application on life, accident, medical or health, critical illness, or disability ever been declined, postponed or accepted at
No
extra premium or modified terms?

2. Did you have any loss or Gain of weight of 10 kgs or more in the last six months? No

3. Do you have any physical deformity / handicap or congenital defect / abnormality? No

4. Have you ever been advised to and / or have undergone any tests, investigations or surgery or had signs or symptoms of any condition, aliment or injury and / or were advised
No
treatment for or have been hospitalized for check-up or treatment other than minor flu, cold or influenza?

5. Have you ever been diagnosed with or investigated for any of the following: No

a. Cardio: High or Low Blood Pressure / Raised Cholesterol / Chest Pain / Palpitation / Rheumatic Fever / Heart Murmur / Shortness of Breath / Heart Attack / Stroke / Any
No
other heart condition

b. Hormonal: High Blood Sugar/ Diabetes / Thyroid or endocrine disorder / Sugar in Urine / Any other hormonal disorder No

c. Respiratory: Asthma / Tuberculosis / chronic cough, chronic bronchitis, emphysema, pneumonia / Any other respiratory disorder No

d. Blood/Cellular: Cancer / Tumor or malignant growth / Leukemia / Anemia / Enlarged lymph nodes/ Any blood disorder No

e. Digestive/Regulatory: Recurrent indigestion / Gastritis / Stomach or Duodenal Ulcer / Hernia / Jaundice / Disorders of the liver / Cirrhosis and Gastrointestinal System/ Any
No
other disease
 f. Mental/Psychiatric / Neurological ailment: Symptoms or ailment relating to Brain Depression / Anxiety / Brain Disorder or disease / Mental / Psychiatric / Transient
No
ischemic attack /Parkinson's disease / Multiple Sclerosis / Nervous disorder / Paralysis or Paraplegia / Epilepsy / Any other mental or psychiatric ailment

g. Neural/Skeletal/Muscular: Musculoskeletal disorders such as Arthritis / Recurrent Back Pain / muscular dystrophies/ musculoskeletal deformities/ Slipped disc or any other
disorder of Spine, Joints, Limbs or Leprosy; / Disorders of Eye, Ear, Nose,Throat including defective sight / Disorder of speech or hearing and discharge from ears / Any other No
disorder

h. Infectious/Contagious: Were you or your spouse ever tested for Hepatitis B or C, HIV /AIDS or any other Sexually Transmitted Disease / Any other disorder No

i. Genitourinary: Hydrocele / fistula / piles / symptoms or ailment relating to Kidney / Kidney Stones/ Prostate, Urinary System or Reproductive System / Any other disorder No

6. Have you had/ are having any other illness or impairment not mentioned above? No

7. Are you presently in good health? Yes

8. Has any of your family member (Parents and Siblings) ever been diagnosed with diabetes, Hypertension, Kidney Failure, Cancer, Heart Attack or any Hereditary Disorder
No
before the age of 60?

9. Have you ever been advised to undergo any surgery or treatment or laboratory investigations (stress ECG, echocardiogram, angiography, MRI/CT scan etc.) by any doctor or
No
specialist?

10. Have you been off work due to illness for a continuous period of 7 days and above during the last 5 years? No

11. Female Life Questionnaire

a. Are you now Pregnant? If Yes, kindly state expected delivery date

b. Have you undergone any gynecological investigations for illness, internal checkups, breast checks such as mammogram or biopsy?

c. Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, fallopian tubes, menstruation, complications during pregnancy or child
delivery or a sexually transmitted disease?

d. Have you suffered from any other disorder of the breast or reproductive organs, abnormal smear test(s) and irregular menses?

12. If answer to any of the question above is yes, kindly give full details noting the question number (attach relevant copies)
Question No.: Details:

13. Family Details (Mandatory if the life to insured is Juvenile/Student/Housewife)

Family Details Name Gender (M / F) Date of Birth Occupation Annual Income ( ) Insurance Details (Existing /Applied for)

Father/Husband

First Child / Sibling

Second Child / Sibling

14. Family Details to be filled for Life Assured only Father Mother Brother Sister Spouse

a. If Alive, Health Status

b. If Deceased, Cause of Death

c. Age at Death/Current Age

VII. EXISTING INSURANCE DETAILS

Do you currently hold or have applied for Life Insurance/Pension/Health (Cancer/Cardiac/Critical Illness)/Personal Accident Policies? Y / N If Yes, kindly provide details as
below:

Life Assured Proposer (If Life Assured is Juvenile/Student/Housewife)

Basic Sum
Type of Insurance (Life/ Health (Cancer/Cardiac/Critical Basic Sum Type of Insurance (Life/ Health (Cancer/Cardiac/Critical Company
Company Name Assured (
Illness)/ Unit Linked /Pension/Personal Accident) Assured ( ) Illness)/ Unit Linked /Pension/Personal Accident) Name
)

Life Insurance
Life Corporation of 1350000
India

VIII. NOMINEE DETAILS (Required only if Proposer & Life Assured are the same) / PARTNER DETAILS (only if 'Partner Care' payout option has been opted )

Base Plan / Rider (Benefit Option) Date of Gender (Male /Female Percentage ( % ) (Do not enter % in decimals & total %
Name Relationship
Name Birth /Transgender) should be equal to 100)

Tata AIA Life Insurance Sampoorna ABOLI

27-05-1987 Female Spouse 100
Raksha Supreme MOGHE

IX. APPOINTEE DETAILS (Required only if Nominee is less than 18 years of age)

Name Date of Birth Gender (Male /Female /Transgender) Relationship

X. PAYMENT DETAILS

Premium Payment Method: Payment via Link

Name of Credit Card/Debit Card Holder: Credit Card/Debit Card Number
Cheque/DD No. Issuing Bank Branch Amount Date: DD/MM/YYYY
Premium# 13200 + Taxes, cesses & levies 2376 = Total Payment 15576 for months initial deposit (To be filled for monthly mode only)
On the first policy/modal anniversary I would like to change the premium payment mode to , subject to policy contract provisions. For Annual/Monthly mode issued policies mode
change shall be accepted only on completion of first policy anniversary. # Premium is exclusive of applicable taxes, cesses & levies. All Premiums are subject to applicable taxes,
cesses & levies which will entirely be borne by the Policyholder and will always be paid by the Policyholder along with the payment of Premium. If any imposition (tax or otherwise) is
levied by any statutory or administrative body under the Policy, Tata AIA Life Insurance Company Limited reserves the right to claim the same from the Policyholder. Alternatively, Tata
AIA Life Insurance Company Limited has the right to deduct the amount from the benefits payable by Us under the Policy. Cheque/DD should be drawn in favor of Tata AIA Life
Insurance Company Ltd. (Proposal No). Do not issue blank cheque.
Renewal Payment Mode: NA

XI. Mandatory Bank Account Details:

Please provide below bank details. Bank details provided should be in the name of Proposer. All policy payouts will be made to the below mentioned bank account through electronic
transfer (NEFT). Payout would be in accordance and subject to terms and conditions of the policy.

Name of Account Holder Bank Account No. Bank Name and Branch Account Type IFSC Code

AKSHAY MOGHE 056601507527 I.C.I.C.I. BANKLTD. KALYANI NAGAR PUNE Saving ICIC0000566

Note: 1. Please provide a cancelled copy of your personalized cheque. If personalized cancelled cheque is not available, attach bank statement showing account holder name, address
and account number. 2. In case of Non-Credit to the given bank account with/without assigning any reason thereof or if the transaction is delayed or not effected at all for any reason of
incomplete information, Tata AIA Life Insurance Co Ltd will not be responsible. 3. Further, the Company reserves the right to use any alternative payout option inspite of opting for
Direct Credit option. 4. If Account type is NRE/NRO then FATCA/CRS-Self Certification Form to be mandatorily completed.

XII. Waiting Period (applicable only for POS products except Immediate Annuity Products):

In case of death of the life insured during the first 45 days from the date of commencement of risk, the claimant shall be entitled to the total premiums paid. Waiting period shall not be
applicable in case of death due to accident.

XIII. DECLARATION & CONSENT

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all
respects to the best of my knowledge and that I am authorised to propose on behalf of these other persons (applicable where the proposer and life insured are different).
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy will
come into force only after full payment of the premium chargeable.
I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but
before communication of the risk acceptance by the company.
I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/ proposer or from
any past or present employer concerning anything which affects the physical or mental health of the person to be insured/ proposer and seeking information from any insurer to
whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer (if any) for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
I confirm that I have understood the contents of this Proposal Form and I am submitting this Proposal Form with all the details which are true and correct. I have not withheld any
material information or suppressed any fact which are essential for issuance of the policy. I also hereby authorize the Company to ascertain all the details from any third parties, as
may be required for assessing the risk.
I agree to undergo all medical tests as determined by the Company for obtaining the policy and I further understand that the Company reserves the right to issue the policy if all the
required criteria are met and in case of any fraud or misstatement being established, the insurer shall take action in accordance with Section 45 of the Insurance Act, 1938 as
amended time to time. I understand that the contract will be governed by the provisions of the Insurance Act, 1938 as amended time to time, the IRDA Act, 1999 and the
Regulations framed there under and that the contract will not commence until the Company's written acceptance of this Proposal Form is received. In case of the life to be insured
being a minor, I further declare and affirm that this proposal of insurance is for the benefit of the life to be insured.
Anti-Money Laundering Declaration: I hereby confirm that all premiums will be paid from bonafide sources and no premiums will be paid out of proceeds of crime related to any of
the offence listed in Prevention of Money Laundering Act, 2002. The Company has the right to peruse my financial profile and also agree that the Company has right to cancel the
insurance contract in case I have been found guilty of any of the provisions of any law, directly or indirectly, having relation to the laws governing prevention of money laundering in
the country, by any competent court of law.
I/We understand that in accordance with the IRDAI (Protection of Policyholders Interests) Regulations, 2017, the insurer is permitted to share policyholder information only with the
statutory authorities. I permit/authorize the Company to collect, store, communicate and process information relating to the Policy/Account and all transactions therein, by the
Company and any of its affiliates or service providers wherever situated including sharing, transfer and disclosure between them or with any entity or entities for the purpose of
underwriting, policyholder servicing and claims; and to the authorities in and/or outside India for compliance with any law or regulation whether domestic or foreign.

Date:
07-10-2021
Place:
Signature/Thumb Signature/Thumb impression of Life Assured OTP 9886 has been used to authenticate your proposal form no. C230378803
Impression of Proposer and its benefit illustration no. 1633602947046 as well as suitability analysis

I hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I undertake to inform you of any changes therein, immediately in
case any of the above information is found to be false or untrue or misleading or misstated, before issuance of the proposal. I, the undersigned confirm that I have verified photocopies
of the proofs submitted along with this proposal form against the originals and certify the same to be true copy.
I declare and confirm that I have carried out necessary suitability analysis while advising this product to the proposer and that the product is suitable to the proposer.

Signature of Agent/ Specified Person/ Broker/ Employee

ACKNOWLEDGEMENT
Tear away portion (To be handed over to the customer)
Proposal Number: ___________________
Dear Customer
We acknowledge receipt of your Cash/Cheque/DD for Rs.______________ by number ______________ dated ___ /___ /___ drawn on _______________ toward's Initial Deposit. We
request you to kindly verify the details filled in the proposal form before signing the same. Please do insist on Official Receipt issued by Tata AIA Life from your advisor within 2 working
days from submission of this proposal form. In case you do not hear from us or do not receive your policy within 15 days from the date of submission of your proposal, please visit us at
www.tataaia.com or call our helpline number 1860 266 9966 (local charges apply) or email us at customercare@tataaia.com
This is only acknowledgement slip and not the premium receipt.

Agent code Agent name Signature of Agent Date of Acknowledgement

Agent code Agent name Signature of Agent Date of Acknowledgement
 IN CASE ANSWERS TO THE QUESTIONS ARE FILLED IN BY A PERSON OTHER THAN THE PROPOSER OR WHERE THE ANSWERS/SIGNATURE OF THE PROPOSER
ARE IN VERNACULAR.
Note: The below must be witnessed by someone other than advisor/employee of the company.
Declaration by Agent/Intermediary of Tata AIA Life Insurance Company Limited
I, _______________________________________ (name) have explained the contents of this proposal to the _________________________________________ (Proposer) in
____________________ (language) and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer responses to the information
sought in the proposal form and I have read out the responses to the Proposer and he/she has confirmed that they are correct.

Date: 07-10-2021
Place:

(Signature of the person making the declaration)

Address of the person making the declaration:

Declaration by Proposer/ Life Assured:

I have understood the contents of this proposal explained to me in ______________ language and confirm that the responses provided by me are correct.

Date: 07-10-2021 Date: 07-10-2021

Place: Place:
Signature/Thumb Impression of Proposer Signature/Thumb impression of the Life Assured

(Prohibition of Rebates) Section 41 - of the Insurance Act, 1938 as amended from time to time: 1. No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the
commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may
be allowed in accordance with the published prospectuses or tables of the insurer. 2. Any person making default in complying with the provisions of this section shall be liable for a
penalty which may extend to ten lakh rupees."
SECTION 45 OF THE INSURANCE ACT, 1938 STATES: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of
policy, i.e. from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later. A policy
of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or
the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or
nominees or assignees of the insured the grounds and materials on which such decision is based. Nothing in this section shall prevent the insurer from calling for proof of age at any time
if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy adjusted on subsequent proof that the age of the life insured was
incorrectly stated in the proposal. For further details, please refer to the Insurance Act, as amended from time to time.
Disclaimers: IN CASE OF A ULIP POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER. Tata AIA Life Insurance Company Limited
is only the name of the Company and any contract bearing the prefix "Tata AIA Life" is only the name of the contract and does not in any way indicate the quality of the contracts, its
future prospects or returns. Premium paid in ULIP is subject to investment risks associated with capital markets & the NAV of the units may go up or down based on the performance of
the funds and factors influencing capital markets and the insured is responsible for his decision. Past performance is not indicative of future results. For more details on risk factors, terms
and conditions please read sales brochure carefully before concluding a sale.

L&C/Advt/2021/May/0626/CAF/V1

1. Please carry valid Identity card to the medical examination center wherever applicable. 2. For cash payment, please visit our nearest Tata AIA Life branch. Please do not handover
cash to Agent. If handed over to the agent, the company will not be liable for any loss. 3. In case there is any change in the particulars given above including Life Assured/Proposer's
health and/or medical and/or financial and/or occupational status and/or being charged with and/or arrested for any criminal offence after the date of proposal but before risk
acceptance by the company; please inform the company. 4. Acceptance of premium does not constitute risk commencement. 5. Risk commencement starts after the acceptance of risk
by the company. 6. Freelook Period: If you are not satisfied with the terms & conditions/features of the policy, you have the right to cancel the Policy by providing written notice to the
Company and receive the premiums after deducting a) Proportionate risk premium for theperiod on cover & b) Stamp duty and medical examination costs including applicable taxes,
cesses & levies, which have been incurred for issuing the Policy. Such notice must be signed by you and received directly by the Company within 15 days from the date of receipt of
the policy document by you or person authorized by you. The said period of 15 days shall stand extended to 30 days, if the policy sourced through distance marketing mode which
includes solicitation through any means of communication other than in person. For Unit Linked Life Insurance products, you would receive the non allocated premiums plus charges
levied by cancellation of units plus fund value at the date of cancellation and after deducting the charges as mentioned in (a) & (b) above.

Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110 CIN: U66010MH2000PLC128403). Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park,
Senapati Bapat Marg, Lower Parel, Mumbai - 400013. 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. For any information including cancellation, claims and complaints, please contact our Insurance Advisor/ Intermediary or visit Tata AIA Life's nearest branch office or
call 1- 860-266-9966 (local charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.
 Name of the Prospect / Policyholder: AKSHAY MOGHE Proposal No: 1633602947046

Age (years) : 33 Gender: Male Name of the Product: Tata AIA Life Insurance Sampoorna Raksha
Supreme
Name of the Life Assured : AKSHAY MOGHE
Tag Line : Non-Linked, Non-Participating Life
Age (years) : 33 Gender: Male Smoker: No Insurance Plan

Policy Term : 38 Years 00 Income Start Age Unique Identification No.: 110N160V02
months (years): NA
GST Rate Year 1: 18.0%
Premium Payment Term : 38 Years 00 Income Rate:
months NA% GST Rate Year 2 onwards: 18.0%

Amount of Instalment Premium 15576 I am red I am red

(Rs.):

Mode of Payment of Premium : Annual

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option: Life option Lumpsum(Rs): 10000000
Sum Assured (Rs): 10000000 Income p.a (Rs): 0

Sum Assured on Death (at inception of the policy) (Rs): 10000000 Income Duration (months): 0

Rider Details

Details of Life Insured/Partner under

Rider Name/UIN^ Benefit Payout
the Benefit Option Return of Benefit Premium Sum Premium
(Benefit
Income premium Option Payment Assured without
Option/Benefit Lumpsum Income
Name Age(yrs) Gender Duration Option Term Term (Rs.) GST (Rs.)
Payout Option) (Rs.) p.a.(Rs.)
(years)

Premium Summary
Base Plan Riders Total Instalment Premium
Instalment Premium without GST (Rs.) 13200 0 13200

Instalment Premium with First year GST (Rs.) 15576 0 15576

Instalment Premium with GST 2nd year onwards (Rs.) 15576 0 15576
 (Amount in Rupees)
Guaranteed# Non - Guaranteed

Policy Single/ Annualised Survival

Year Premium Benefit / Other Benefits, if Maturity Death Min Guaranteed Surrender Special Surrender
Loyalty any Benefit Benefit Value Value
Additions
1 13200 NA NA NA 10000000 0 NA

2 13200 NA NA NA 10000000 0 NA
3 13200 NA NA NA 10000000 0 NA
4 13200 NA NA NA 10000000 0 NA

5 13200 NA NA NA 10000000 0 NA
6 13200 NA NA NA 10000000 0 NA
7 13200 NA NA NA 10000000 0 NA

8 13200 NA NA NA 10000000 0 NA
9 13200 NA NA NA 10000000 0 NA
10 13200 NA NA NA 10000000 0 NA

11 13200 NA NA NA 10000000 0 NA
12 13200 NA NA NA 10000000 0 NA
13 13200 NA NA NA 10000000 0 NA

14 13200 NA NA NA 10000000 0 NA

15 13200 NA NA NA 10000000 0 NA

16 13200 NA NA NA 10000000 0 NA
17 13200 NA NA NA 10000000 0 NA

18 13200 NA NA NA 10000000 0 NA

19 13200 NA NA NA 10000000 0 NA
20 13200 NA NA NA 10000000 0 NA

21 13200 NA NA NA 10000000 0 NA

22 13200 NA NA NA 10000000 0 NA
23 13200 NA NA NA 10000000 0 NA

24 13200 NA NA NA 10000000 0 NA
25 13200 NA NA NA 10000000 0 NA

26 13200 NA NA NA 10000000 0 NA

27 13200 NA NA NA 10000000 0 NA
28 13200 NA NA NA 10000000 0 NA

29 13200 NA NA NA 10000000 0 NA
30 13200 NA NA NA 10000000 0 NA
31 13200 NA NA NA 10000000 0 NA

32 13200 NA NA NA 10000000 0 NA
33 13200 NA NA NA 10000000 0 NA
34 13200 NA NA NA 10000000 0 NA

35 13200 NA NA NA 10000000 0 NA
36 13200 NA NA NA 10000000 0 NA
37 13200 NA NA NA 10000000 0 NA

38 13200 NA NA NA 10000000 0 NA

Note: "Annualized Premium" shall be the premium payable in a year under a non-single pay option chosen by the policyholder, excluding the taxes, rider
premiums, underwriting extra premiums, loading for modal premiums, if any.
"Single Premium" shall be the premium payable under a single pay option chosen by the policyholder, excluding the taxes, rider premiums, underwriting
extra premiums if any.

#The benefits illustrated are as at the end of the policy year.

I _______________________________ (name), have explained I _______________________________ (name), having received the information
the premiums and benefits under the product fully to the prospect / with respect to the above, have understood the above statement before entering
policyholder. into the contract.
 Place: i am red
Date: Signature of Agent/ Intermediary/ Official Date: Signature of Prospect/ Policyholder

Unique Reference Number - L&C/Advt/2021/May/0627 (Rider - L&C/Advt/2020/Dec/1539)

Tata AIA Life Insurance Company Ltd. (IRDA of India Regn No. 110) (CIN: U66010MH2000PLC128403)
Registered and Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai- 400013
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.
For more information, Call the Tata AIA Life Insurance Company Ltd Helpline number1860-266-9966 (local charges apply) or Visit us at: www.tataaia.com

(I)V.96.00/FY2021-2022_Q2/RELEASE 01-07-21/EXPIRY 30-09-2021 BC 07-10-2021,04:55 PM

Adakine, Vilas

From: Hunkeri, Sunil

Sent: 18 October 2021 13:45
To: Adakine, Vilas
Cc: Gurjar, Hariom; Nikam, Anant (Randstad Consultant)
Subject: Fwd: Tata AIA Life - C230378803_Pending Documents Upload

Dear Vilas

Please upload this trail mail also .

Regards,
Sunil Y. Hunkeri
BROCA-PUNE
8806038548

From: Akshay Moghe <mogheakshay@gmail.com>

Sent: Sunday, October 17, 2021 1:28:46 PM
To: Tata AIA Life <Customer.Info@tataaia.com>; Tata AIA Life Customercare <Customercare@tataaia.com>
Cc: Hunkeri, Sunil <Sunil.Hunkeri@tataaia.com>; ranjana.paradkar@gmail.com <ranjana.paradkar@gmail.com>
Subject: Re: Tata AIA Life - C230378803_Pending Documents Upload

“External mail. Open with Caution!”

Dear TATA AIA Team,

As per discussion with customer care team over telephone, I'm writing this email with regards to the query/follow-up document request.

Please refer to my email response dated: 14-Oct-2021.

I've shared all available documents with me with regards to treatment re:pain in testicles - such as prescription, medicine/consultant bills etc. Please
note - there were no such tests done as requested by you, details below -

1
Any further follow-up including any tests/USG etc. for this treatment were advised only in case discomfort still persist after 5 days of medicine
course.

As clarified earlier and mentioned in previous email, consulting doctor advised me that I should take prescribed medicine course for 5 days and only
visit him for follow-up in case of any discomfort/pain persists or does not go away. As per doctors advice, USG/any further tests are to be
done/needed only in case need for follow-up arise as mentioned above. Since discomfort was completely resolved there was no follow-up done and
no tests performed as advised by doctor during first visit, so there are no such reports or documents for me to share.

Also, I'm not a medical personnel and probably I'm not able to explain whole case over email, so in case of any further queries please call me on
registered number for discussion - it will be easier for me to discuss/explain the treatment.

Dear Sunil,

I've received your contact from Ms. Ranjana Paradkar (cc'd) from NJ Insurance Ltd. via whom I've applied for this term insurance.

I've been struggling to explain to your team regarding non-availability of test reports as they were not done as per doctor's advice (explained above).
All available documents have been already shared for the said domiciliary/OPD consultation/treatment.

Could you please help me to get this resolved or advise alternative as I am unable to share reports for tests which never happened/not required as per
doctor's advice unless follow-up was needed.

Thanks & Regards,

Akshay Moghe
+91 9527071900

On Sun, Oct 17, 2021, 9:38 AM TATA AIA Life <Customer.Info@tataaia.com> wrote:

Dear AKSHAY MOGHE,

We thank you for choosing Tata AIA Life for your Life insurance needs.

Please be informed that we have received the documents uploaded online by you. However, to complete the application process, we would require
the below mentioned documents from your end since the documents provided by you earlier were not legible

1) Reports pertaining to Urine routine and microscopic, culture and sensitivity and bilateral inguino scrotal region USG as advised as per reports
received along with up to date Follow records

2
You can upload the above documents by clicking on the URL Link provided below

https://sellonline.tataaia.com/wps/portal/TATAAIA/TATAAIA_SO/#!/pending/document/C230378803

Note- Please upload a recent colour passport size photograph, along with the documents selected above in the document upload section.We will not
be able to issue your life insurance policy until you submit the above mentioned pending documents in an acceptable format. In case of non receipt
of pending documents within --- days, your application will stand cancelled & your premium amount will be refunded back to your account.

Life Insurance not only protects your present, but also secures future for your family and loved ones. You are a step closer towards securing your
future. Hence we request you to kindly upload the above mentioned documents at the earliest.

Should you have any query, you may call on our helpline number 1-860-266-9966 (Local Charges Apply) between Monday to Saturday 9am-9pm.

Thank you and have a great day!

With Regards,
Tata AIA Life eSales Team.

Address and Registration Number: Tata AIA Life Insurance Company Limited. (Regn. No.:110)CIN No. U66010MH2000PLC128403
Registered Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.L&C/Misc/2017/Oct/372

This is a system generated e-mail. We request you not to reply to this message.

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS

IRDA of India clarifies to public that

 IRDA of India or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums.
 IRDA of India does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details
of phone call, number.

IMPORTANT NOTICE:
The information in this email (and any attachments) is classified. If you are not the intended recipient, you must not use or disseminate this information. If you have received this email in error, please immediately
notify me by "Reply" command and permanently delete the original and any copies or printouts thereof. Although this email and any attachments are believed to be free of any virus or other defect that might affect
any computer system into which it is received and opened, it is the responsibility of the recipient to ensure that it is virus free and no responsibility is accepted by Tata AIA Life Insurance Co. Ltd or their subsidiaries
or affiliates either jointly or severally, for any loss or damage arising in any way from its use.

3
 Name of the Prospect / Policyholder: AKSHAY MOGHE Proposal No: 9639531

Age (years) : 33 Gender: Male Name of the Product: Tata AIA Life Insurance Sampoorna Raksha
Supreme
Name of the Life Assured : AKSHAY MOGHE
Tag Line : Non-Linked, Non-Participating Life Insurance
Age (years) : 33 Gender: Male Smoker: No Plan

Policy Term : 38 Years 00 Income Start Age Unique Identification No.: 110N160V02
months (years): NA
GST Rate Year 1: 18.0%
Premium Payment Term : 38 Years 00 Income Rate:
months NA% GST Rate Year 2 onwards: 18.0%

Amount of Instalment Premium (Rs.): 15576 I am red I am red

Mode of Payment of Premium : Annual

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option: Life option Lumpsum(Rs): 10000000

Sum Assured (Rs): 10000000 Income p.a (Rs): 0

Sum Assured on Death (at inception of the policy) (Rs): 10000000 Income Duration (months): 0

Rider Details

Details of Life Insured/Partner under

Rider Name/UIN^ Benefit Payout
the Benefit Option Return of Benefit Premium Sum Premium
(Benefit
Income premium Option Payment Assured without GST
Option/Benefit Lumpsum Income
Name Age(yrs) Gender Duration Option Term Term (Rs.) (Rs.)
Payout Option) (Rs.) p.a.(Rs.)
(years)

Premium Summary
Base Plan Riders Total Instalment Premium
Instalment Premium without GST (Rs.) 13200 0 13200

Instalment Premium with First year GST (Rs.) 15576 0 15576

Instalment Premium with GST 2nd year onwards (Rs.) 15576 0 15576
 (Amount in Rupees)
Guaranteed# Non - Guaranteed
Policy Single/ Annualised Survival
Year Premium Benefit / Other Benefits, if Maturity Death Min Guaranteed Surrender Special Surrender
Loyalty any Benefit Benefit Value Value
Additions
1 13200 NA NA NA 10000000 0 NA
2 13200 NA NA NA 10000000 0 NA
3 13200 NA NA NA 10000000 0 NA
4 13200 NA NA NA 10000000 0 NA
5 13200 NA NA NA 10000000 0 NA

6 13200 NA NA NA 10000000 0 NA
7 13200 NA NA NA 10000000 0 NA
8 13200 NA NA NA 10000000 0 NA
9 13200 NA NA NA 10000000 0 NA
10 13200 NA NA NA 10000000 0 NA

11 13200 NA NA NA 10000000 0 NA
12 13200 NA NA NA 10000000 0 NA
13 13200 NA NA NA 10000000 0 NA

14 13200 NA NA NA 10000000 0 NA
15 13200 NA NA NA 10000000 0 NA

16 13200 NA NA NA 10000000 0 NA
17 13200 NA NA NA 10000000 0 NA
18 13200 NA NA NA 10000000 0 NA

19 13200 NA NA NA 10000000 0 NA
20 13200 NA NA NA 10000000 0 NA

21 13200 NA NA NA 10000000 0 NA
22 13200 NA NA NA 10000000 0 NA

23 13200 NA NA NA 10000000 0 NA
24 13200 NA NA NA 10000000 0 NA
25 13200 NA NA NA 10000000 0 NA

26 13200 NA NA NA 10000000 0 NA
27 13200 NA NA NA 10000000 0 NA
28 13200 NA NA NA 10000000 0 NA

29 13200 NA NA NA 10000000 0 NA
30 13200 NA NA NA 10000000 0 NA
31 13200 NA NA NA 10000000 0 NA
32 13200 NA NA NA 10000000 0 NA
33 13200 NA NA NA 10000000 0 NA

34 13200 NA NA NA 10000000 0 NA
35 13200 NA NA NA 10000000 0 NA
36 13200 NA NA NA 10000000 0 NA
37 13200 NA NA NA 10000000 0 NA
38 13200 NA NA NA 10000000 0 NA

Note: "Annualized Premium" shall be the premium payable in a year under a non-single pay option chosen by the policyholder, excluding the taxes, rider
premiums, underwriting extra premiums, loading for modal premiums, if any.
"Single Premium" shall be the premium payable under a single pay option chosen by the policyholder, excluding the taxes, rider premiums, underwriting extra
premiums if any.

#The benefits illustrated are as at the end of the policy year.

 I _______________________________ (name), have explained the I _______________________________ (name), having received the information with
premiums and benefits under the product fully to the prospect / respect to the above, have understood the above statement before entering into the
policyholder. contract.

Place: i am red
Date: Signature of Agent/ Intermediary/ Official Date: Signature of Prospect/ Policyholder

Unique Reference Number - L&C/Advt/2021/May/0627 (Rider - L&C/Advt/2020/Dec/1539)

Tata AIA Life Insurance Company Ltd. (IRDA of India Regn No. 110) (CIN: U66010MH2000PLC128403)
Registered and Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai- 400013
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.
For more information, Call the Tata AIA Life Insurance Company Ltd Helpline number1860-266-9966 (local charges apply) or Visit us at: www.tataaia.com

(I)V.97.00/FY2021-2022_Q3/RELEASE 01-10-21/EXPIRY 31-12-2021 004503123BCSRSRV1N1 15-11-2021,07:01 PM

Adakine, Vilas

From: Hunkeri, Sunil

Sent: 18 October 2021 13:45
To: Adakine, Vilas
Cc: Gurjar, Hariom; Nikam, Anant (Randstad Consultant)
Subject: Fwd: Tata AIA Life - C230378803_Pending Documents Upload

Dear Vilas

Please upload this trail mail also .

Regards,
Sunil Y. Hunkeri
BROCA-PUNE
8806038548

From: Akshay Moghe <mogheakshay@gmail.com>

Sent: Sunday, October 17, 2021 1:28:46 PM
To: Tata AIA Life <Customer.Info@tataaia.com>; Tata AIA Life Customercare <Customercare@tataaia.com>
Cc: Hunkeri, Sunil <Sunil.Hunkeri@tataaia.com>; ranjana.paradkar@gmail.com <ranjana.paradkar@gmail.com>
Subject: Re: Tata AIA Life - C230378803_Pending Documents Upload

“External mail. Open with Caution!”

Dear TATA AIA Team,

As per discussion with customer care team over telephone, I'm writing this email with regards to the query/follow-up document request.

Please refer to my email response dated: 14-Oct-2021.

I've shared all available documents with me with regards to treatment re:pain in testicles - such as prescription, medicine/consultant bills etc. Please
note - there were no such tests done as requested by you, details below -

1
Any further follow-up including any tests/USG etc. for this treatment were advised only in case discomfort still persist after 5 days of medicine
course.

As clarified earlier and mentioned in previous email, consulting doctor advised me that I should take prescribed medicine course for 5 days and only
visit him for follow-up in case of any discomfort/pain persists or does not go away. As per doctors advice, USG/any further tests are to be
done/needed only in case need for follow-up arise as mentioned above. Since discomfort was completely resolved there was no follow-up done and
no tests performed as advised by doctor during first visit, so there are no such reports or documents for me to share.

Also, I'm not a medical personnel and probably I'm not able to explain whole case over email, so in case of any further queries please call me on
registered number for discussion - it will be easier for me to discuss/explain the treatment.

Dear Sunil,

I've received your contact from Ms. Ranjana Paradkar (cc'd) from NJ Insurance Ltd. via whom I've applied for this term insurance.

I've been struggling to explain to your team regarding non-availability of test reports as they were not done as per doctor's advice (explained above).
All available documents have been already shared for the said domiciliary/OPD consultation/treatment.

Could you please help me to get this resolved or advise alternative as I am unable to share reports for tests which never happened/not required as per
doctor's advice unless follow-up was needed.

Thanks & Regards,

Akshay Moghe
+91 9527071900

On Sun, Oct 17, 2021, 9:38 AM TATA AIA Life <Customer.Info@tataaia.com> wrote:

Dear AKSHAY MOGHE,

We thank you for choosing Tata AIA Life for your Life insurance needs.

Please be informed that we have received the documents uploaded online by you. However, to complete the application process, we would require
the below mentioned documents from your end since the documents provided by you earlier were not legible

1) Reports pertaining to Urine routine and microscopic, culture and sensitivity and bilateral inguino scrotal region USG as advised as per reports
received along with up to date Follow records

2
You can upload the above documents by clicking on the URL Link provided below

https://sellonline.tataaia.com/wps/portal/TATAAIA/TATAAIA_SO/#!/pending/document/C230378803

Note- Please upload a recent colour passport size photograph, along with the documents selected above in the document upload section.We will not
be able to issue your life insurance policy until you submit the above mentioned pending documents in an acceptable format. In case of non receipt
of pending documents within --- days, your application will stand cancelled & your premium amount will be refunded back to your account.

Life Insurance not only protects your present, but also secures future for your family and loved ones. You are a step closer towards securing your
future. Hence we request you to kindly upload the above mentioned documents at the earliest.

Should you have any query, you may call on our helpline number 1-860-266-9966 (Local Charges Apply) between Monday to Saturday 9am-9pm.

Thank you and have a great day!

With Regards,
Tata AIA Life eSales Team.

Address and Registration Number: Tata AIA Life Insurance Company Limited. (Regn. No.:110)CIN No. U66010MH2000PLC128403
Registered Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.L&C/Misc/2017/Oct/372

This is a system generated e-mail. We request you not to reply to this message.

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS

IRDA of India clarifies to public that

 IRDA of India or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums.
 IRDA of India does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details
of phone call, number.

IMPORTANT NOTICE:
The information in this email (and any attachments) is classified. If you are not the intended recipient, you must not use or disseminate this information. If you have received this email in error, please immediately
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or affiliates either jointly or severally, for any loss or damage arising in any way from its use.

3
Adakine, Vilas

From: Hunkeri, Sunil

Sent: 15 November 2021 20:35
To: Adakine, Vilas
Cc: Gurjar, Hariom
Subject: Fwd: Acceptance of without LSPO option policy number C230378803
Attachments: Sampoorna Raksha Supreme.pdf

Dear Team,

Please upload customer trail mail and confirm the same.

Regards,
Sunil Y. Hunkeri
BROCA-PUNE
8806038548

From: Akshay Moghe <mogheakshay@gmail.com>

Sent: Monday, November 15, 2021 8:30:05 PM
To: Hunkeri, Sunil <Sunil.Hunkeri@tataaia.com>
Subject: Acceptance of without LSPO option policy number C230378803

“External mail. Open with Caution!”

Dear Team,
I am agree and accept policy without LSPO (Life stage plus option).
Kindly issue my policy asap.

Thanks & Regards,

Akshay Moghe

--

1
Akshay Moghe
mogheakshay@gmail.com

2
 FIRST PREMIUM RECEIPT
Date: 17/11/2021
PERSONAL DETAILS
Policy Number C230378803 Plan Name Tata AIA Life Insurance Sampoorna Raksha Supreme (110N160V02)
Policy Owner Name AKSHAY MOGHE Life Assured Name AKSHAY MOGHE
Email ID MOGHEAKSHAY@GMAIL.COM Distributor/Agent Name NJ Insurance Brokers Pvt Ltd
Contact no. 9527071900 Distributor/Agent Contact number
PAN details ARDPM5034G

PREMIUM DETAILS
Premium Amount Due (In Rs.) 13200.00 Payment Mode Annual
Goods & Service Tax (GST) 2,376.00 Next Premium Due on 07/10/2022
Total Amount (In Rs.) (a) 15576.00 Excess Amount (In Rs.) (b-a) : 0.00
Amount Received (In Rs.) (b) 15,576.00

TAX BENEFIT DETAILS

Sec 80 C Sec 80 CCC Sec 80 D
15576.00 .00 .00

PAYMENT DETAILS
Receipt Number Receipt Date Amount (In Rs.) Payment Method
TB1336985 07/10/2021 15,576.00 Online Payment

Please note:
• This document can be used as a proof for claiming deduction while filling your tax returns and tax benefits would be applicable
as per the prevailing tax laws.
• Payments made through modes other than cash are subject to clearance including through electronic mode payments.
• Any excess premium will be adjusted towards premium due in the current financial year or due in the next three months, whichever is
later. Else premium will be auto refunded post 15 days.
• Applicable govt taxes, surcharge, cess including GST would be charged in accordance with applicable Laws and Company will have the
right to recover the same from the policyholder.
• Please refer to the policy document for detailed terms and conditions and our website for FAQ on applicable tax benefits.

GST Details
Base Premium Taxable Value CGST .00% SGST/UTGST .00% IGST 18.00% Reverse Charge
` 13200.00 ` 13200.00 ` .00 ` .00 ` 2376.00
Tata AIA Life Insurance State MAHARASHTRA Tata AIA Life Insurance GST IN 27AABCT3784C1ZD SAC Description Life Insurance
Policy Owner's GST State CHHATTISGARH Policy Owner's GSTIN NOT REGISTERED SAC Code 997132

#RakshakaranHero
Consolidated Revenue stamp duty paid: Notification No. Mudrank – CSD/179/2019/4939, dated 16th October, 2019 vide receipt number
MH006751891201920M dated on 26th September, 2019.
PAN: AABCT3784C. Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) GIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th
Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. 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. For any information including cancellation, claims and complaints, please contact our Insurance Advisor /
Intermediary or visit Tata AIA Life's nearest branch office or call 1-860-266-9966 or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.

BEWARE OF SPURIOUS/ IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving
FRAUD PHONE CALLS! such phone calls are requested to lodge a police complaint.

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