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    (Name of All Insured's Whom Extension Is Required) : Explore Policy Extension Request Form

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    karanjai
    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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    (Name of All Insured's Whom Extension Is Required) : Explore Policy Extension Request Form

    Uploaded by

    karanjai
    4 views2 pages
    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.

    Original Description:

    Ext Form

    Original Title

    Extension Form

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    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.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    4 views2 pages

    (Name of All Insured's Whom Extension Is Required) : Explore Policy Extension Request Form

    Uploaded by

    karanjai
    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.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    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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