user registration for Aviva Group Term Life

Select Master Policy Holder

                    Master Policy Holder Name
                    
                    Master Policy No
                    
                    Unique Application Number

Client Particulars (First Life)

                    Title
                    
                    First Name
                    
                    Last Name
                    
                    Date of Birth

                    Gender
                    
                        STD Code
                        
                        Contact Number
                        
                    Email
                    
                    Mobile Number

Mailing Address

City Name

Pin Code

occupation

Client Particulars (Second Life, if Applicable)

If coverage to second life is applicable

Second Life Insured Information

                        Title
                        
                        First Name
                        
                        Last Name
                        
                        Date of Birth

                        Gender
                        
                            STD Code
                            
                            Contact Number
                            
                        Email
                        
                        Mobile Number

Mailing Address

City Name

Pin Code

occupation

Declaration of Good Health

Nominee Information

                        Title
                        
                        First Name
                        
                        Last Name
                        
                        Relationship with borrower

Date of Birth

Note: In case of joint lives, Nomination is applicable only in the event of simultaneous death of both the insured lives or in the event of death of the last surviving insured life. Please provide Apointee details if nominee is minor:

Insurance Particulars

Cover Start date

Primary Life

Second Life

Sum Assured

Primary Life

Second Life

Premium Frequency

Premium Amount
(excluding GST)

Primary Life

Second Life

Cover Tenure
(in months)

Primary Life

days

Second Life

days

* Sum assured and cover tenure will be as per master policy quotation agreed by the Master Policy Holder

Medical questionnaire (Long form)

Transaction Information

Premium Amount :

23000/-

Tax Amount :

230/-

Total Premium Amount :

230/-

Transaction Information

Transaction Number

Transaction Date

I agree to abide by the terms and conditions of the scheme.I hereby declare that the above statements are true in all respects. I agree that the information provided above will form the basis of my admission to the scheme. I further declare that If any information is found to be untrue, scheme membership shall be forfeited. I/we heereby declare that the contents of this application for insurance, have been fully explained to me/us & I/we have fully understood the significane of the prposed contract.I agree that my membership will be terminated on the expiry of loan term as per loan schedule agreed between Master Policy Holder and Aviva Life Insurance (applicable for lender-borrower schemes).

For Lender- Borrower Schemes of 'Regulated Entities' only

I/We hereby authorize Insurer to pay outstanding loan amount (if any) from the claim proceeds payable on the admissibility of any claim on the happening of an event giving rise to claim under the certificate of insurance issued to me/us to Master Policyholder and balance claim amount after deducting outstanding loan amount from total claim amount to the Nominee.

Declaration of Good Health (DOGH): DOGH will be assessed on scheme to scheme basis and maybe called upon / waived depending upon the risk attributes of the scheme. Content of the MEF(Membership Enrollment Form) may be modified from time to time to capture the member related information as per the scheme's feature.