Renewal/Extension Form of ICICI Lombard Travel and Student Insurance


Renewal/Extension Form of ICICI Lombard Travel Insurance

Proposal form for Extension/Renewal of ICICI Lombard policy
Initial Policy No :
Full Name of Applicant :
Full Name of Father or Residence Address:
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,__________, S/o__________, policy no __________ valid from __________to __________, would like to extend my policy from __________ to __________ date. The details of claims that have been preferred by me or will be preferred by me on the existing policy are as stated herein below:. OR I__________ , r/o__________, policy no __________ have not filed any claims on the original policy period and will not be filling any claims on the original policy. Further, I do not anticipate any medical scenario in the extended policy period that will lead to a claim. I,__________, having policy no __________ hereby declare that I am in sound physical and mental health at the time of purchase of this policy and I am not presently suffering from any physical or mental illness, disease or condition that can result in a claim on this policy. Thanking You,
I declare that the information provided in this renewal form is correct.

Insurance is the subject matter of the solicitation.

Renewal/Extension Form of ICICI Lombard Travel Insurance