·,,, 1 ' f ,.'~ • / ,, • r.

,/

.AVIVA
·1.Life! lnsu;ance l

Maturity Payout Form

1. The form must be duly filled and signed by the Claimant (PohcyHolder / As~tgnr.e / Trustee) and c;m be submitted .Jt any Aviva Branch or
sent by courier to Aviva's Head Office
2. The PolicyHolder/Claimant 1s required to carry Original Docurncnh for venfic:ahon ,11 the Aviva Branch . SP.lf-attestat,on on documents is a
mandatory requirement and any alterations/corrections In the form need to be duly signed by the PohcyHolder/Cla,mant
3. In case the PolicyHolder authonzes any third person to submit the dcx:umenVs on his/ her behalf, the customer's authonzation letter &
depositor's ID proof is required
4. ms (Tax Deduction at Source). if applicable will be imposed as per applicable Income Tax Laws
Documents Required for Maturity Documents Required for Aviva Annuity Policy

✓Self attested copy of Photo ID Proof I I Annuity Proposal Form with recent Photograph
ycopy of Cancelled Cheque/Self attested Bank Statement with I l Self Attested copy of Age/ID Proof and Address Proof
pre-printed name and Account Number reflecting the last 3 [ _I Copy of PAN Card (in case of non availability, Form 60 is mandatory)
months' transactions
I~ - i Form 15 G/15 H/ Exemption Certificate (Subject to IDS applicability)
Address Proof (in case of Non-Residents or change in address)
~Onginal Polity Document
[ ] PEP Declaration, GSTIN Addendum and E-Form

POLICYHOLDER DETAILS

: I . ,
L._ ' :___ '__ --
Name of the Policyholder/Assignee/Trustee;_l~ U_ ~ U::J I_/J l___~ i.B_l!-:.Li LBI___ !____ L___ ~- _! _ L_ .. _ _
Current Address S tf_ "-' ' L LA __ ~ J1 lU i ~LQI_____ ! P lO L ,M IO !_ H Ji :JLE __ \JJ A L _A
1

City J). -E J::t ~~ ~ iV ltl_ State \J L 1.IT.~ \~ l{i l '1'--UJ ~ lr:1 d) L__ l__ Pin Code ~ -~ - ~ _C!_ ~
1
1
_ ~
Mobile Number _'1 ~ L! · ~ I :-5 LI 1-l lJ LS! 5 /_ Alternate Number i__ l_ __ ~- _~ ___ __ ___ _

Email ID _cl ri__h L i _s_ ~h L.9.. i~ l~ ~ -[.tn :~ I~ 1£,~l-~l.Q_ !~ l_ :__ [_ ~--- i __ ~--I __ ~- __ __ __
PAN No (Mandatory) :.A :__GlU\ ~ - i'-""L.Ql9 l_P. [_6_ ~

Residential Status (Tick as applicable)

'---1
~ esident D Non Resident
Residence for Tax Purposes in Jurisdiction(s) outside India: D Yes*
*If ·ves·. kindly fill the CRSIFATCA Addendum available on the Aviva Website or at any Aviva Branch

BANK ACCOUNT DETAILS

Account Holder's Name . N '. .J LS. •- H LA;___ ~ l.8 l_!.. [ \ l f)_ l. ! __ i.. ;
(as appearing in the Bank records)

Bank Name ;C · ~ I N :T :R ,A_·L- 0 :A l N ~" l I O I F! · 1. , N : D: \ ' ')

Branch Address lft ;y p ~ ! t.. 0 ' \.. [_ \..- l6'. ;_tr, It . l
,_f>_ I~ I~ \l, ,A ,N eV fl ' 0 'r; 1-t P- A O u N
Account Number IJ _ i_9 j 1 ; 9 ! S" '-< :6 ,~ ,5 i .\ !.. !
..... -~ ~-·
---=--•
. - .......,~..
""'-..
·· ··-··:~· o,;iiAii_;
IFSC Code(11 digits) L~ l.lEJ [..N '..0 :~ :s ~ 3 ~ S. l y =:~:~1~~.,,::~~;:---~ -;;,~~;;;;~-----·__-_-__-_- -:-.-.-.,~ I
1

MICR Code (9 digits) ~ j~ [g LO ' l . 61C, I_ O; 6 ......,...,~.........

~ ~ LMRO ,lf(;j / MIJJ.S((.QOf .-.,c,oog;;IJO
~.
T 11•.J.MrtS"S.11' 1Ultll I r - --11 :u

Account Type 0 Savings Account !J Current Account I I NRE* NRO .,......... _ ,,.,.,,.., ,,.,~.,

* For NRE Account Type, kindly submit Pre Printed cancelled Cheque of NRE Account and Self Attested Bank Statement/Passbook of NRE
Account from wnich
premiums are remitted. Av'iva will not be responsible for any delay or non-credit due to incorrect banking details.

. F-Aviva-MPf (Aviva (Payout)- Maturity Payout FormY Ver:2.3'"3"' Nov 2018/Public

 [!:.·:;·AVI\IA
I life tnsur•nc. I

ANNUITY OPTION {Apphrnble fo1 l1 1"1\ s1on MAt1111ty only)

'
I_.... 1M f..ak,wtng o,tiOft fOf •vefltnt AMI~ \

~':'' ~~_,,.,,,,.-,• 1M, ol the p()l1L)' ~Ilk? (nol ,no"' 1h,'l11 113"1 of 11w poll<.y voluP) towards lumr, sum wlthdr;mal artd woold l1kP !l"J blJ1/ ¥1n1Jr?!/
"'-" ' ' (__ · _ (Nam,• th.- Indian Lili• ln~ur,1ri(e Conip,iny from \.'AllCh yuJ W('JIJl<f lrkP to bu'f\
Annuity) fflf the ba~ntt' ~rnount ·· '
OR
I d\Ql1 100% of ttle matt.inly vatue towards buying annwty Imm < ~
(Name of ttie ~ L,ft. lh5utanc:e Company from wtuch you would like lo bJy Annuity) 7

DECl AR ~TI ON

, ~ dedal'e that the details furnished above are true and correct to the best of my/our knovvledge and belief and I undertake to int-0rm ,,r.;11,•
of an\' changes therein, 1mmed1ately. In case any of the above information is found to be false or untrue or misleading or mlS(ep<esenting.
\!We ~ aw-an:- that Vwe may be held liable for it.

for ~ I Q - I henc>by consent and authorize the Company to collect, store, communicate and process information rel.atlng to the poltey
and all transactions therein. by the Company and any of its affiliates wherever situated including sharing, transfer and disclosure between them
and to the authorities in and/or outside India of any confidential information for compliance with any law or regulation whether domestJc °'
tore.gr\. .

~~ Place _ _X)_f_H_il-~A~O~V_N_
· _ __

YEltNA(] ■ AR DEC1.ARA110N (Dedamion when the Policyhokler has affixed thumb impression or has signed in any language
adla-a... English)- I hereby declare and certify that I have explained the content of this form to the Policyholder in the language under·
stood by him/her and that the Policyholder has affixed his/her thumb impression/ signature on this form in my presence. after fully undem,md- ,
ing the content thefeof.

0eaaranrs Name N ls H A w A\.. \ ~

Oedarant's Addres-5 & Contact No. S b\.,J l, A k\-\ V }lU \) J; H SlA \)v N U T TAQA\<.BAN D
(2..,~l"tL.-'---'M~·><:.o..LH..L·....,Q.~A~E-..::.
v,)__,_,A'--"\ec:.,..;l\.___ _:i"""-"~:J..g~o'-o= --.,,::l,=------ Declarant's Signature _ _.....,~,.,.._____...,___.C\__._)~-----~~
,...,
--

Date \ 'J o 7 .:t_ ~ ~o

. . .: Kmdly •Slbnl1. a mpy of the Photo ldenbty Proof of the Oedarant

FOR BRANCH USE ONLY

Sewke .RequesttD _ _ _ _ _ _ _ _ _ _~ - - - - - - - - - -- - - - - - - - - - -- -

Branch Name _ _ __ _ __ __ _ _ _ _ _ _ _ _ _ __ Employee Code

Avhl• Ufe Insurance CompMy lndt. u.mt.cl

oJ
C&ntomer Servke HelpUne Number Email
Avwa Tower, Sector Road, Opposite -Golf Cou~ 1800-103-77-66 (Toll frae) customerservicesOavivamdia .com
DLF Phase-V, Sector 43, Gurugram-122Q03 0124•,?70.9046
www.alriv-aindia.com

1 · : f-AvNa'MPf (Aviva (Payout}- Maturity Payout form)/ Ver.2.319"' Nov 2018/Pubbc

 rs ,,11....-~

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r11Ai"1r1 ~ I Enrollment No.: 2080/88101/000&i

\ I \ "'I ·\ ,

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To
~rr ~
N Nisha Walia
~ W/0 Sunil Kumar Walia , /'
8 Sewla Khurd Opp Himalayan Drugs factory ~r-J'I'
;:: Mohabbey Wala
M
Mohbewala ~~
Chakrata Dehradun T\\
8 Uttarakhand 2413002 '
~ 9411512785 )
N

EIIIIIIIIIHlll llll lllll 1111111111111111

M P339295030FT

Jti4chl 3ntlff P-ffqi' / Your Aadhaar No. :

·-----------·-··----~ ------------------------~-x-
. i
• ~ . . 1 111~• __. --
• ___ _, 17 ST
~rr 'Ql~T
" ' _,:.. --

Nisha V-i alia

-,
It ~~/DOB: 30/03/1968
~/Female

7857 8554 8311

3ITTITT"
 ~ ~ 3lt. ~ ~ PAYABLE AT Al l 8 RANCHE::::i
f.jt ~ .-i:rr 1Jf <l ~ cf, q
il>-<'19;<. i?t;-<1«5:➔• ii'tHf&- 6·
~ (lftufi) ~ -
MV(PG)C~LEGE,KARANAPUR,DEHRAOUN,UTTARAKHAND-0 I lM
IDD .
i MI Y! YI YIYI
IFSC: ClftJ02 83284
'-~t-·- - - --- --
.,·,:::•~~t:~~
1 lit" 9mli 'cfit or· Beare r

NISHA . WALIA
~ ~ ~ cf>"'~ I Please sign above
DAVDEH
 II
AVIVA
Life lnsurn noo
deep Building , 7. Tolstoy Marg. New Delhi-11 o 001 . India
Aviva Life Insuranc e Compan y India Ltd .. 2nd Floor, Prakash
www.avivaindia. com

SCHEDULE
: TDS294 5195 Product Name Aviva Ohan Sanchay Product Code TDS UIN : 122N069V01
policy Number

policyholder Insura nce Details

Nisha Walia
Name Commen cement Date 31/03/2010
30/03/19 68
Date of Birth Premium paid at inception Rs.30,000.00
42 Rs. 183.00 Per Month
Age Mortality Premium
Female 10
sex Policy Tenm
Viii.- Sewlakh urd, Mohabb ewala, Sum Assured Rs.300,000.00
Address
Maturity Date 31/0312020

Dehradu n 248110
Uttarakh and
India
Self
Relationship with
the insured

Nomin ation Details (Under section 39 of Insurance Act. 1938 )

Insured Nomine e(s)

Nisha Walla
Name
30/03/19 68 Name Sunil Kumar
Date of Birth
42 Name NIA
Age
Female Name NIA
Sex
Address Viii .- Sewlakh urd, Mohabb ewala,
(In case of minority of the Nominee )
Appoin tee
Dehradu n 248110 Name NIA

Uttarakh and
Act
India (In case of Insurance under the Mamed Women·s Propeny
Married
Benefi ciaries 1874 )
Marital Status
Age Admitte d-Drivin g Licence Name NIA
Whether Age
Admitted Name NIA

Any Special Condit ions

Insured
Niaha Walla

Benefits Extra Mortality Flat Extra (per 1000

Rating of sum assured)

Death Benefit NIA NIA

 Various fees under this product

~ ¥ ~-·'--

1) Policy Administration Fee: .

This is a fee levied at the beginning of
each policy month ftom the Rs, 20 per month,
Policyholder Deposit Account

2) Premium Allocation Fee:

This is a percentage of the premium
appropriated towards fee from the
premium received, This fee is levied at
the time of receipt of the premium , Rs, 500-9,999 20% 7.50% 5%

Rs,10,000 & above 15% 7.50% 5%

3) Mortality Premium:
This is the cost of life insurance cover Applicable Mortality Premium as per your age is specified in the Schedule inclusive of prevailing
under the Policy. This is levi Se -
beginning of each month from
Policyholder Deposit Account

S1,1_rtender Fee as a percentage of

Poli'cyholder Deposit Account Value
4) Surrender Fee:
This is a fee levied at the time of 1 - 60 20%
surrender of the Policy as a
percentage of Policyholder Deposit 61 & above 0%
Account value as on date of surrender.

In addition, the Company may apply Market Value Adjustment (MVA) on the Surrender
Value on the date of surrender payment, based on the need for the company to realize the
investments and based on the market value of the underlying assets as on that date.

5) Services Tax: Service Tax will be deducted on monthly basis from Policyholder Deposit Account on the prevailing
Service Tax Rate.

Endorsements, if any and effective date : N/A

All premiums and benefits under this Policy are payable in Indian Rupees .
This Schedule forms an integral part of the Policy Document and should be read in conjunction with it _
cfor Address icir -Correspon-denci/ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- ----- --

Aviva Life Insurance Company India Ltd. Aviva Tower, Sector Road , Opp Golf Course,DLF - Phase V , Sector. 43,
Gurgaon - 122003 (Haryana)
Stamp Duty of Rs 60 00(Rupees Sixty only J paid by Demand Draft vide Challan No . No F.10(777)/COS(HQ)/Con.duty/08110756 dated 03-Mar-10

C:(v-J,_),~.) y .
Authorised Signatory
Date : 11/06/2010

On behalf of Aviva Life Insurance Company India Limited, this policy has been executed at Delhi.
 II
AV IVA
/ Ufa lnsurn nc-~

Illustration* - Benefits for Policy No: TDS2945195

/

Product Features :
1) Name Of the Product
Aviva Ohan Sanchay Mrs Nisha Walia
Name of the Life Insured
2) Unique Identification No.
122N069V01 Age of the Life Insured 42 Years
3) Sum Assu red
300,000.00 /
4) Policy Term
10 Years
5) Amount of Installment Prem ium

Prem ium Prem ium Prem ium Prem ium

at i n 1st year In 2nd year In 3rd year
Premium
in 4th year
Prem ium
In 5th year
Prem ium
In 6th year
Premium
in 7th year
Premium
in 8th year
Premium
In 9th year
Premium
in 10th year
I
Inception Post
Inception

30,000 .00 0 .00 30, 000 .0 0 30,000.0 0 30, 000.00 30 ,000 .00 30 ,000 .00 30 ,000.00 30 ,000 .00 3 0 ,000.00 30 .0 0 0 .00

.. Assuming gross Investment return of 6 °/o p.a . Assuming gross investment return of 10-4 p.a. I
§
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0 I

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1 30 ,00 0 .00 4 .500 .00 25.500 .00 0 .00 240.00 1,987.98 6,727.98 24,730.22 0.00 324 ,730 .22 1 .987.98 6 ,727 .98 25.703.00 0 .00 325 ,703.00
2 30,0 00.00 2 .250.00 27 ,750.00 0 .00 240.00 1.987.98 4,477.98 53,329.25 0 .00 353,329.25 1,987 .98 4 ,4TT 98 56,451 29 0 .00 356,451.29
3 30,000 .00 2 ,250. 00 27 .750 00 0 00 240.00 1,987.98 4,477.98 83,644.23 66,9 15.38 383,644.23 1.9 87 .98 4,477 .98 90.27 4 42 72.21953 390 ,274 .42
4 30 ,000.00 1 ,500.00 28.500 .00 0 .00 240 .00 1,987.98 3,727.98 116 ,573.10 93 ,258.48 416 ,573.10 1.987.98 3 ,727 98 128 3°'4 86 102.643 89 428 .304 .86
5 30 ,000 .00 1,50 0 .00 28.500 .00 0 .00 24 0 .00 1,987.98 3,727.98 151 ,477.70 121,182.16 451,477 .70 1,987.98 3 ,727 .98 170. 138.34 136 ,110 .67 470 ,138 34
30 ,000.00 1 ,500.00 28 ,500.00 0 .00 240 .00 1.987 .98 3,727.98 188,476.58
6 188,476 .58 488,476 .58 1.9 87.98 3 ,727 .98 216. 155 17 216 .155 .17 516.15517
1 ,500.00 28 .500 00 000 240 00 1,987.98 3,727.98 227 ,695.40
7 30,0 00. 00 227 ,695 .40 527 ,695.4 0 1 ,987.98 3 ,727 .98 266 ,773 68 266 ,773 .68 566 ,773 68
28 ,500 .00 O 00 240.00 1,987.98 3,727.98
8 30 ,0 00.00 1,50 0 .00 269 ,267 .34 269 ,267 .34 569,26 7 .34 1.987 .98 3 .727 98 322.454 .05
240 00 1.987.98 322,454 05 622 ,454 05
30,000.00 1,500.00 2 6 ,500 .00 000 3,727.98 313,333.60
9 Jll ,333.60 613 ,333.60 1.987 98 3 .727 .98 383.702 .45 383 ,702 ◄t; 683 ,7 02 .45
10 30,000 00 1 ,500 .00 28.500.0 0 coo 240.00 1,987 98 3,727.98 360 ,04 3 .84 360 ,043 84 660 ,043.84 1,987.98 3 ,727 .98 451.07569 451 ,0 75.69 751 ,075 69

Pauu 8 of 20
Notes :
1
The benefit illustr t' · . . . . · f h
year. a ion ,s based on the assumption that the premium amount payable remains the same during the year and the same Is payable at the beginning. o eac
2. Service Tax and Ed .
3. Th ucation Cess would be levied as per the applicable laws.
e Fees assumed for b .
a ove illustration are:
a. Premium Allocation Fee :

Premium Paid
At inception Subsequent 4th Policy
premiums up to Year
3rd Policy Year onwards
Rs .500-9999
20% 7.50% 5%
Rs.10000 & above 7.50%
15% 5%

b. Policy Administration Fee:

Rs.20 will be deducted each month from Policyholder Deposit Account.

c. Mortality Premium :

This is age specific level premium for providing life cover and will be applied on Sum Assured . It will be deducted on monthly basis from Policyholder Deposit
Account.

d. Surrender Fee:

Month of Surrender
Surrender Fee
1-24 100%
25-60 20%
61 & above 0%

4. For more details of terms and conditions , please read sales brochure carefully before concluding a sale

5. Benefits under the policy are variable with returns based on future performance of your Life Insurance Company. This illustration is based on assumed gross investment
return at 6% and 10% scenario. These assumed -rates of return are not guaranteed and they are not upper or lower limits of what you might get back , as the value of your
policy is dependent on a number of factors.

Page 9 of 20