	Call : +91 (80) 41101026

Renewal/Extension Form for Bajaj Allianz Travel and Student Insurance

Extension/Renewal Form of Bajaj Allianz policy
Initial Policy Schedule No. (eight characters):
Name of Applicant :
Applicant Date of Birth:	(dd/mmm/yyyy)
Policy Name:
Email :
Phone:
Initial Policy Start date :	(dd/mmm/yyyy)
Initial Policy End date :	(dd/mmm/yyyy)
Duration of Initial Policy :
Number of Days Extension Required:
Have you Filed Any Claims on the Initial Policy?	Yes No
I hereby declare that I am in Good Health and that no event has occurred which can give rise to any claim in my earlier policy period mentioned above I request that my policy be extended further for __________ days so that the total duration of cover for me overseas would be _______________. I reconfirm that I am in good health and that I had given a proposal form at the time of taking the policy and that this declaration shall be the basis for the issuance of policy for the additional days requested above and it will be subject to the standard terms and conditions and special clauses as applied to my policy specifically. Thanking You,

Insurance is the subject matter of the solicitation.

Extension/Renewal Form of Bajaj Allianz policy