Renewal Form of Cholamandalam Travel and Student Insurance

1. Policy Number

2. Policy Holder Name

3. Policy Holder Date of Birth

(dd/mmm/yyyy)

4. Policy Name

5. Email

6. Phone

7. Original Policy Start date

(dd/mmm/yyyy)

8. Original Policy End date

(dd/mmm/yyyy)

9. Duration of Initial Policy

10. Total days of extension & Date till when the extension required

11. Reason for Extension / If policy already expired, reason for delay in extension

12. Are you in good health now? (Y/N)

Yes No

13. 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

14. Please confirm if any claim is made during the expiring policy (If yes, mention the Claim)

Yes No

I hereby solemnly declare that above information given by me is true of my knowledge and understanding.

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