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Policy Extension Request Form

This document is an explore policy extension request form. It collects details of the policy holder such as name, product name, policy number, risk start and end dates, as well as contact information. It requests the date to which the policy should be extended and the reason for extension. The form also asks if any claims have been made on the policy and collects details of those claims or medications if applicable. The policy holder must declare their health status and sign and date the form, with the understanding that misrepresented information could lead to policy cancellation or denied claims.

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karanjai
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7 views2 pages

Policy Extension Request Form

This document is an explore policy extension request form. It collects details of the policy holder such as name, product name, policy number, risk start and end dates, as well as contact information. It requests the date to which the policy should be extended and the reason for extension. The form also asks if any claims have been made on the policy and collects details of those claims or medications if applicable. The policy holder must declare their health status and sign and date the form, with the understanding that misrepresented information could lead to policy cancellation or denied claims.

Uploaded by

karanjai
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Explore Policy Extension Request Form

Policy Holder Details

NAME (Name of all


insured’s whom extension
is required)
PRODUCT NAME
POLICY NUMBER
RISK START DATE
RISK END DATE
EMAIL
CONTACT NUMBER

Extension Details

Extension Till (Date)


Reason for Extension

CLAIM DETAILS

CLAIM MADE (YES/NO)

Declaration

I declare and undertake that I haven’t made any claim on my above mentioned policy and no claims
pending till date.

I am in good health and not suffering from any physical or mental illness, disease or conditions nor I am
aware of any such conditions that can result in future claim. Further, I am not on medication for any
illness or disease.

OR

I have made/filled a claim on above mentioned policy. The details of claim that has been filed /made by
me on first policy (including previous extension made if any) are as follow:

1)…….

OR
I am currently on following medication for _______________________:

1)…………………

Insurance company has the rights to cancel the policy or not to honor my claim in case or any mis-
representation of facts in this letter.

POLICY HOLDER NAME:

SIGNATURE:

DATE:

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