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Renewal/Extension Form for RELIANCE Travel and Student Insurance

Proposal form for Extension/Renewal of RELIANCE policy
Original Reliance Policy Schedule No (16 characters):
Type of Policy/Plan:
No of Insureds:
Insured Name & Insured’s Company:

Insured(s) Date of Birth:
Email & Phone:

Policy Period - Inception (dd/mmm/yyyy):
Policy Period - Expiry (dd/mmm/yyyy):           
Reason for Extension:
Extension Period Required:
Are you in good health now? (Y/N): Yes No
Has any Extension made to the policy (Y/N)(If “Yes”, Provide the total duration of the Policy as on expiry of the last extension): Yes No   days
Please confirm if any claim is made during the expiring policy (If yes, mention the Claim): Yes No 
I hereby solemnly declared that above information given by me is true of my knowledge and my understanding.