Basic Information

Life Assured Details

Name of Life Assured *

Gender

Date Of Birth *

Age *

Mobile No

Proposal Number

Freeze Date

Are you currently employed in Army/Para Military?

Proposer Details

Same as Above

Yes No

Name of Proposer

Gender

Date Of Birth

Age

Member Details

Cover Type

Individual

Family Individual

Family Floater

Product Information

PPT

Mode

Modal Premium

Annual Premium

Monthly Income

Sum Assured

Base Premium Multiple

Do you want rider?

HospiCash Benefit

Amount (Per day)

Days Covered (Per Year)

Sum Assured

SurgiCash Benefit Sum Assured

CritiCash Benefit Sum Assured

Choose Survival Period

7 Days 0 Day

	Hospicash Benefit			Surgical Benefit Sum Assured	Criticash Benefit Sum Assured	OPD Care Rider	ATPD Sum Assured

Accidental Total & Permanent Disability Sum Assured

Waiver of Premium

Surgical Benefit

Multi-Stage critical illness Benefit

Installment Premium

Increase in Policy Term

Premium shown above excluding GST, Tata AIA Vitality Wellness Program Discount, any other Discount or loading

Benefits payable upon minimum 24 hours of hospitilisation

Customers needs to choose per day benefit and number of days cover per year

Per Day Benefit	Rs 2500 to 20,000/- in multiple of 500
No of Days per year	15/30/45/60 days
ICU Benefit	2X of Per day benefit opted

Annual Limit

Annual Sum Assured i.e. (Per day benefit x no of days per year)

Lifetime Limit

900 days (Benefit will terminate on exhaustion of lifetime limit)

Category	No of Surgeries	% of SA payable	Examples
Listed Surgeries	133
Category 1	23	25%	Amputation of foot or Hand
Category 2	57	50%	Knee or hip replacement
Category 3	43	75%	Angioplasty
Category 4	10	100%	CABG
Day Care	Unlimited	Min 10% of Sum Assured or Rs 50000/-(Annually 3 and Lifetime 30)	Cataract,Radiotherapy or Chemotherapy for Cancer
Non-Listed Surgeries	Unlimited	10%	All surgeries meeting surgical definition and requiring 24 hours hospitilization

Annual Limit

Max up to opted Sum Assured

Lifetime Limit

Entire Surgical SA claimed for 10 times of Annual Sum assured 30 claims for Day care surgeries during policy term

Category	No of CIs	% of SA payable
Minor Critical Illness's	22	25% of Sum Assured or Rs. 5,00,000/-
Major Critical Illness's	33	100% less any minor claim alreday paid
Catastrophic Critical Illnesses	2	150% less any minor claim alreday paid

Lifetime Limit

Max up to opted Sum Assured

EMR

Flat Extra

Fund Details

Fund Strategy

Debt Fund

Equity Fund

Fund Choice

Fund Name	Fund Allocation %	SFIN Codes

Fund Name 1

Fund Name 2

Total

Total must be 100%

Withdrawal Plan

DIY Withdrawal Plan

Yes No

Withdrawal Start Year

Withdrawal Plan Option

Rate % Amount Rs.

Withdrawal Plan rate

withdrawal Plan payout frequency

Riders

Tata AIA Vitality Wellness Program

Get premium discount on all riders you select

Health Care

Protection

Other Riders

Joint Life Details

Life-2

Name

Date of Birth

Age

Gender

Child Information

Children		% Sum Assured
		Total : 0%

Basic Information

Life Assured Details

Proposer Details

Other Details

Member Details

Adult Members

Children

Product Information

Fund Details

Fund Choice

Withdrawal Plan

Riders

Joint Life Details

Withdrawal

Child Information

Medical Underwriting

Summary

Generate BI

Basic Information

Life Assured Details

Proposer Details

Other Details

Member Details

Adult Members

Children

Product Information

Hospicash Benefit

Benefits payable upon minimum 24 hours of hospitilisation

Surgicash Benefit

Criticash Benefit

OPD Basic

OPD Standard

OPD Essential

OPD Advance

OPD Advance+

OPD Comprehensive

Fund Details

Fund Choice

Withdrawal Plan

Riders

Joint Life Details

Withdrawal

Child Information

Medical Underwriting

Summary

Generate BI

Add Partner