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Renewal/Extension Form for Bajaj Allianz Travel and Student Insurance

Extension/Renewal Form of Bajaj Allianz policy
Policy Number: (Eg: OGXXX....XXXXXXXX)
Name of Applicant :
Applicant Date of Birth:	(dd/mmm/yyyy)
Policy Name:
Email :
Phone:
Policy Start date : (First policy start date in case of 2nd renewal)	(dd/mmm/yyyy)
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,

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