{"id":2093,"title":"Aviva AnnuityPlus Proposal Form da-65","purpose":"proposal","insurer":{"slug":"aviva-life-insurance","name":"Aviva Life Insurance Company India Limited"},"source_pdf":"https://www.avivaindia.com/sites/default/files/TIA%20Telugu.pdf","sha256":"850bc125cdd4245021448a1f464d2991fbdef752d17633ceb9049a6016164434","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) applying for the Aviva AnnuityPlus insurance product to provide personal, nominee, and plan details for policy issuance.","notes":["Use capital letters for filling the form.","Leave spaces between parts of names and addresses.","Counter sign any alterations, overwriting, or ink changes.","Proof of age is mandatory.","Only NEFT mode is allowed for quarterly and monthly annuity frequency.","Existence certificate required annually or at specified intervals depending on annuity option.","Attach original documents as proof where required.","For NRI or Person of Indian Origin not residing in India, fill the NRI questionnaire."],"title":"Aviva AnnuityPlus Proposal Form da-65","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of the Annuitant","fields":[{"help":"Write your full name in capital letters with spaces between parts.","type":"text","label":"Full Name : THIS IS HOW YOUR NAME WILL APPEAR ON THE POLICY CERTIFICATE. PLEASE LEAVE A SPACE BETWEEN EACH PART OF THE NAME.","options":["Mr.","Mrs.","Ms.","Dr."],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Father's Name","options":["Mr.","Dr."],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","NA"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Unmarried","Married","Widow(er)","Divorced","NA"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"No. of Children","options":["1","2","3","Greater than 3"],"required":false,"pdf_field":""},{"help":"Specify nationality if not Indian or PIO.","type":"choice","label":"Nationality","options":["Indian","Foreign National","Person of Indian Origin","Specify Nationality"],"required":true,"pdf_field":""},{"help":"Specify country if not residing in India.","type":"choice","label":"Residential Status","options":["Residing in India","Not Residing in India","Specify Country of residence"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Communication Address","options":["Residence","Permanent","Office"],"required":true,"pdf_field":""},{"help":"Include c/o, s/o, w/o, d/o, h/o, f/o wherever necessary. Leave spaces between address parts.","type":"text","label":"Current Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Include c/o, s/o, w/o, d/o, h/o, f/o wherever necessary.","type":"text","label":"Permanent Address (IF DIFFERENT FROM CURRENT RESIDENTIAL ADDRESS)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Educational Qualification","options":["Post Graduate","Graduate","Diploma","12th Pass","Below 12th","Others (Specify)"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation","options":["Salaried","Business Owner","Self-employed","Student","Housewife","Retired/Pensioner","Agriculturist","Others (Specify)"],"required":false,"pdf_field":""},{"help":"Fill only if occupation is student.","type":"text","label":"If student (a) Course presently pursuing","options":[],"required":false,"pdf_field":""},{"help":"Fill only if occupation is student.","type":"text","label":"(b) Name of Institution","options":[],"required":false,"pdf_field":""},{"help":"Fill only if occupation is student.","type":"text","label":"(c) Duration of Course","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Your Designation","options":[],"required":false,"pdf_field":""},{"help":"If yes, provide details.","type":"yes-no","label":"Is your occupation associated with any specific hazard (e.g. Chemical factory, mines, explosives, corrosive chemicals etc.)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Organisation/Business","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Attach proof of age document.","type":"choice","label":"Age proof","options":["School/College Certificate","Municipal Records","Defence ID Card","Passport","Others (Specify)"],"required":true,"pdf_field":""},{"help":"Provide PAN number if available.","type":"text","label":"Income Tax PAN Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination/Beneficiary Details (Applicable for option II,III & IV only)","fields":[{"help":"","type":"text","label":"Name of the Nominee/Beneficiary (*Under section 39 of the Insurance Act 1938)","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Include landmark, pin code, city/village, district, state, phone and mobile numbers.","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Explain reason for nomination if nominee is not parent/spouse/child.","type":"text","label":"If the nominee/Beneficiary specified above Is any person other than your parent/spouse/child, give reasons for such nomination In the space provided below:","options":[],"required":false,"pdf_field":""},{"help":"Provide appointee's name, relationship to minor, date of birth, address, phone, mobile, and signature.","type":"group","label":"If Nominee/Beneficiary Is a Minor, please give details of the appointee (should be a Major)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the plan applied for","fields":[{"help":"Aviva AnnuityPlus","type":"text","label":"Name of the Plan","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Annuity Option","options":["Life Annuity","Annuity guaranteed for 5 years and life thereafter","Annuity guaranteed for 10 years and life thereafter","Annuity guaranteed for 15 years and life thereafter","Annuity for life increasing @ 3% per annum simple"],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Purchase price","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you funding the purchase price through the maturity proceed of an existing pension policy.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If annuity payable is less than Rs. 500, mode will be changed to higher level automatically.","type":"choice","label":"Annuity frequency","options":["Yearly","Half-Yearly","Quarterly","Monthly"],"required":true,"pdf_field":""},{"help":"For NEFT mode, attach cancelled cheque and submit signed NEFT mandate.","type":"choice","label":"Preferred mode of payout","options":["Cheque","NEFT (National Electronic Fund Transfer)"],"required":true,"pdf_field":""},{"help":"Provide bank account number, bank name, account type (Saving/Current/NRO/NRE), MICR code (9 digits).","type":"text","label":"Bank Details (For Annuity Payout)","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of maturity","options":[],"required":false,"pdf_field":""},{"help":"If yes, specify if less than 1/3rd or 1/3rd of the fund value at vesting.","type":"yes-no","label":"Commutation opted","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, mention the additional amount you want to pay.","type":"yes-no","label":"Do you want to increase the purchase price","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration & Authorization","fields":[{"help":"Sign or provide thumb impression.","type":"signature","label":"Signature / thumb impression of the Annuitant","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration (to be handwritten by the Annuitant)","fields":[{"help":"Write the declaration in your own language in the provided box.","type":"text","label":"Handwritten Vernacular Declaration","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Declarant's Name and Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of declarant","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Advisor","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of life to be insured/proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Aviva AnnuityPlus annuity product proposal","attachments":["Proof of age document","Cancelled cheque (for NEFT mode)","Duly completed and signed NEFT mandate"],"declarations":["The proposer declares that all information given is true and complete and understands the importance of full disclosure.","The proposer authorizes release of relevant employment, medical, and insurance information to and from the company for risk assessment.","If the proposal is filled by another person, the proposer confirms the contents have been fully explained and understood.","The proposal form will form part of the insurance contract if accepted by the company.","The proposer agrees to the terms under Insurance Act sections 41 and 45 regarding rebates, fraud, and policy contestability."],"dropped_labels":6},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customerservices@avivaindia.com","label":"General Enquiries- Customer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"stomer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"email","value":"weconnect@avivaindia.com","label":"General Enquiries- Partner Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Senior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-103-7766","label":"General Enquiries- Customer Toll Free","level":null,"hours":"All Days","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Jeevan Bima Plan\nGuaranteed Savings Plan\nULIP Plans\nPAY PREMIUM\nGeneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\ns","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"0124-2709046","label":"General Enquiries- Customer","level":null,"hours":"All Days","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Guaranteed Savings Plan\nULIP Plans\nPAY PREMIUM\nGeneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@av","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-103-8000","label":"Call (Toll Free) - For Kerala users","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"eneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-180-2111","label":"General Enquiries- Partner Toll Free","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"vices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 99","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"0124-2709000/46","label":"Corporate Office Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Office\n401-A, 4th Floor,\nBlock A, DLF Cyber Park,\nSector-20, NH-8, Gurugram,\nHaryana-122 016, India.\nTelephone Number:\n0124-2709000/46\nEmail:\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-767757677","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"+91-7677576775","label":"Give a Missed Call","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"24-2709000/46\nEmail:\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-7677576775\nSMS\n\"Aviva\"to 5676737\nInsurance is the subject matter of the solicitation.\nIRDAI Reg No.\n122\n|\nCIN\n              :\nU660","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"sms","value":"\"Aviva\"to 5676737","label":"SMS Service","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":":\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-7677576775\nSMS\n\"Aviva\"to 5676737\nInsurance is the subject matter of the solicitation.\nIRDAI Reg No.\n122\n|\nCIN\n              :\nU66010DL2000PLC107880\nAviv","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"complaints@avivaindia.com","label":"Contact Grievance Officer Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"iries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor\nsearch\nTERM","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91 9999346907","label":"Contact Grievance Officer Phone","level":1,"hours":"Mon-Fri, 9am-6pm","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"0-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor\nsearch\nTERM\n                                                            INSURANCE\nAviva Smart Re","fetched_at":"2026-10-20"},{"purpose":"gro","channel":"address","value":"401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016","label":"Complaint Redressal Officer (CRO) Address","level":2,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"examine your issues and provide you impartial resolution. The CRO can be reached at :\nComplaint Redressal Officer(CRO).\n401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016\nEmail :\ncro@avivaindia.com\nLevel 3\n: Insurance Ombudsman Scheme.\nThe insurance Ombudsman is empowered to receive and co","fetched_at":"2026-10-20"},{"purpose":"gro","channel":"email","value":"cro@avivaindia.com","label":"Complaint Redressal Officer (CRO) Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"edressal Officer(CRO).\n401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016\nEmail :\ncro@avivaindia.com\nLevel 3\n: Insurance Ombudsman Scheme.\nThe insurance Ombudsman is empowered to receive and consider complaints from any","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/aviva-life-insurance/2093-aviva-annuityplus-proposal-form-da-65"}