Renewal Form of Cholamandalam Travel and Student Insurance

1. Policy Number
2. Policy Holder Name
3. Policy Holder Date of Birth
   (dd/mmm/yyyy)
4. Policy Name
5. Email
6. Phone
7. Original Policy Start date
(dd/mmm/yyyy)
8. Original Policy End date
(dd/mmm/yyyy)
9. Duration of Initial Policy
10. Total days of extension & Date till when the extension required
  
11. Reason for Extension / If policy already expired, reason for delay in extension
12. Are you in good health now? (Y/N)
13. Has any Extension made to the policy (Y/N)(If “Yes”, Provide the total duration of the Policy as on expiry of the last extension)
   days
14. Please confirm if any claim is made during the expiring policy (If yes, mention the Claim)
 
I hereby solemnly declare that above information given by me is true of my knowledge and understanding.
 
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