ARMED FORCES QUESTIONNAIRE ÑsÒeègÇtÈeÉ fêqïiÇnÇ
Name of Proposed insured __________________________________
fêÂÇgÈa gÉiÇ ÑtgÇ gèvÈz– eÇi
Application Number_____________________________
AÇÑgce eiólü
(Please give accurate answers to all questions and return to the company)
(ck–ÇLlÈ si fêqïl s°Ì›Ô sWÈLü Dœl cÈA¥Ë J L°ÇeÉLÊ ÑfôlÇ¥Ë)
Questions (strike out whichever is not applicable)
.fêqï (ÑjDøNÊXÈL fêjÊjè eÊÑtø LÇVÈ cÈA¥Ë)
Answers
Dœl
1. Rank (Officer / JCO / NCO). Give
details
.fc (AfôÈslü/JCO/NCO) | gÈglZÉ cÈA¥Ë
2. What branch of Services are you in?
Please provide details.
AÇfZ ÑLDø qÇMÇl ÑsgÇÑl AR¥È? .ck–ÇLlÈ gÈglZÉ
fêcÇe Ll¥Ë |
Military/paramilitary/special forces/police / etc
sÇilÈL/A¢ÔsÇilÈLÈ/sóa¦ gÇtÈeÉ/ÑfÇmÈsü/ BaèÇcÈ
3. Corps/ Arms LfÔsü/.g©ÊLdÇlÉ cn
4. Trade (Exact nature of duties)
ÑVêXü (QÇLÈlÈl sWÈLü fêLÎaÈ)
5. Present place of posting (place and
state) gœÔiÇel Ñfǻȃ– ÄÇe (ÄÇe J lÇSè)
6. Are you engaged in any hazardous
activities like aviation, diving, parachuting,
bomb disposal,etc ?
Yes .tø
No eøÇ
If yes give details
AÇfZ gÈiÇeQÇneÇ, XÇBhȃ–, fÇlÇQÊVȃ–, ÑgÇiÇ e» LlÈgÇ,
BaèÇcÈ hnÈ ÑLÓZsÈ gÈf†eL LÇjÔèÑl sõqÈñ» LÈ?
jcÈ tø ÑaÑg gÈglZÉ cÈA¥Ë
7. Are you currently serving in or are you
under orders to proceed to any troubled
area? If yes,please provide details and
length of service.
AÇfZ ÑLÓZsÈ sisèÇfÌ›Ô AˆnÑl LÇjÔèla gÇ LÇjÔè LlÈgÇLÊ
eÈÑ¡Ôq fÇBR¥È LÈ? jcÈ tø, ck–ÇLlÈ gÈglZÉ J ÑsgÇl AgdÈ
fêcÇe Ll¥Ë |
8. Are you engaged in counter insurgency
operations? If yes give details.
AÇfZ gÈÑcêÇt gÈÑlÇd LÇjÔèLêiÑl sõqÈñ» LÈ? jcÈ tø ÑaÑg
gÈglZÉ cÈA¥Ë |
9. Do you handle weapons? If yes please
provide details.
AÇfZ AÃqà gègtÇl Ll¥È LÈ? jcÈ tø ck–ÇLlÈ gÈglZÉ
cÈA¥Ë |
10. Please provide your current medical
category and details accordingly.
ÑstÈ tÈsÇgÑl ck–ÇLlÈ AÇfZz– gœÔiÇel XÇvlÉ ÑqêZÉ J
gÈglZÉ fêcÇe Ll¥Ë
Uw /Non-Med Q/Ver 1.0/1st April 2011
I hearby declare and agree that the above particulars and answers are complete and
true and this questionnaire will form part of the contract of the desired insurance on my
life.
iøÊ HacücóÇlÇ ÑOÇrZÇ LlÊRÈ J lÇSÈ Ñj Dfl abè J DœlNÊXÈL s°Ì›Ô J saè J HtÈ fêqïiÇnÇ ÑiÇl SÉge DfÑl bÈgÇ
B…Èa QÊvÈl HL Aõq Ñtg |
Date________________________(DD/MM/YY)
aÇlÈM _____________ (cÈe/iÇs/grÔ)
Signature/ Thumb Impression of Insured___________________
fêÂÇgÈa/ cÂMa/VÈf QÈtï______________________________________
A Joint Venture between Dabur Invest Corp & Aviva Interna onal Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph‐ V, Sector 43, Gurgaon‐122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi‐110001. India
XÇglü BeüÑh» LÑfÔÇÑlseü J AhÈhÇ B€lüeèÇseÇmü ÑtÇmüXȃ– mÈiÈÑVXü i¤Ñl HL iÈnÈa gègsÇk
AhÈhÇ SÉgegÉiÇ L°ÇeÉ B˜ÈAÇ mÈiÈÑVXü
iÌMè LÇjÔèÇnk–: AhÈhÇ VÇpÇlü, ÑsLÞlü ÑlÇXü, Nmüfô ÑLÇsÔ s´Ë–MÑl, ÑfôSü5 , ÑsLÞlü 43, NÊlNÇJø-122003, tlÈk–ÇZÇ hÇla
fŠ–ÉLÎa LÇjÔèÇnk–: cÈóaÉk– itmÇ, fêLÇqcÉfü gÈmüXȃ–, 7 Vmü»k– iÇNÔ, eÌAÇ cÈmñÉ-110001 hÇla
Tel/ ÑfôÇeü:+91 (0) 124 270 9000 Fax/ fôèÇL: +91 (0) 124 257 1210.
www.avivaindia.com Email/ BÑimü:[email protected]