Renewal/Extension Form for Bajaj Allianz Student Insurance

BAJAJ ALLIANZ INSURANCE

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Renewal/Extension Form for Bajaj Allianz Student Insurance

For Student renewal, complete the Student Extension Form, and send a scanned copy of the same document. Along with this document, send a scanned document of University I20.

Proposal form for Extension/Renewal of Bajaj Allianz policy
Initial Policy Schedule No :
Name of Student:

Student Date of Birth:	(dd/mmm/yyyy)
Policy Name:

Email :

Phone:
Original Policy Start date :	(dd/mmm/yyyy)
Original Policy End date :	(dd/mmm/yyyy)

Duration of Initial Policy :

Number of Days Extension Required:

Have you Filed Any Claims on the Original Policy?	Yes No
I hereby declare that there has been NO CLAIM whatsoever till date, against the above Insurance Policy and further state and confirm that there has been NO CHANGE till now in my Personal physical & medical condition since the date of issue of the first policy. You are now requested to kindly treat this letter as an Application / Proposal for the New Insurance Policy as requested above. I declare that the information provided in this application is correct. Please do the needful at the earliest and oblige. Thanking You,

Insurance is the subject matter of the solicitation.

For Student renewal, complete the Student Extension Form, and send a scanned copy of the same document. Along with this document, send a scanned document of University I20.