Renewal Form of Reliance Travel and Student Insurance

1. Insured Name & Insured's Company
    
2. Existing Reliance Policy No.
3. Type of Policy/Plan
4. Insured(s) Date of Birth
  
5. Email & Phone
  
6. Existing Policy Period
7. Existing Policy Period - Expiry
          
8. Total days of extension & Date till when the extension required
  
9. Reason for Extension / If policy already expired, reason for delay in extension
10. Are you in good health now? (Y/N)
11. Has any Extension made to the policy before(Y/N) (If Yes, Provide the total duration of the Policy as on expiry of the last extension)
 
12. Confirm if any claim is made during the expiring policy (If yes, mention the Claim)
 
  I hereby solemnly declared that above information given by me is true of my knowledge and my understanding.
 
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