Aviva Life Insurance

New Proposal Online Premium Payment

Proposal Number

Customer Name

Email ID

Date of Birth

_(MM/DD/YYYY)

Contact Number

Total Payable Amount

I hereby declare that I am the bonafide Customer of Aviva Life Insurance Company India Limited (hereinafter referred to as Aviva) and the premium for this policy is being paid from my legally declared and assessed sources of income only. I am fully aware that AVIVA does not accept premium payment through a third party credit card/debit card/internet banking account. I agree and understand that Aviva has the right to peruse my financial profile and also reserves the right to cancel this premium payment transaction or even the insurance contract with due intimation to the Customer, in case I am found violating provisions of any law relating to prevention of money laundering, or if there has been a contravention or evasion of any Act, Rules, Regulations, Notification or Directions issued by any Regulatory Authority in India.

Do you wish to set an eStanding instruction on your UPI, Credit or Debit card?

Please note, by doing so, your future premiums would be automatically debited from your UPI, Crebit or Dedit card.

Onetime Mandate Setup (via UPI up to 5 lacs only).

I want to opt for Standing Instruction on my UPI, Credit or Debit card.

No, I don’t want a Standing Instruction.

Convenience fee will be charged in case premium payment is being made using a Credit Card(VISA/MASTER/AMEX/DINERS/RUPAY etc.).

In case there is an error message/transaction failure page, inspite of debit of premium amount from your bank account, please wait for 2-3 working days before re-attempting payment. It will be either credited to your policy or reversed back to the source of payment after receiving confirmation from your bank. Once money is received at our end, an acknowledgement of receipt of premium shall be sent to your registered email id and registered mobile no within 24 hours.