Date: 01-SEP-2015

Place: Pune
To,
The Manager, Bajaj Allianz General Insurance Company
Office: _________________
Subject: Extension of policy
Reference: Insured Name: __Akshay Dattatraya Walvekar__
Policy Number: __OG-16-9906-9910-00018746__
Policy period: from __05-AUG 2015______to __03 SEP 2015______
Date of Birth: __05-APR-1991________ Age: __24_____________
Dear Sir.
I hereby declare that I am in Good Health and that no event has occurred which can give rise to any
claim in my earlier policy period mentioned above
I request that my policy be extended further for ___267___ days so that the total duration of cover for
me overseas would be ____298_____days upto ___30th May 2016______.
The past history of any illness / disease /ailment / treatment / consultations is as follows :
____None_________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I reconfirm that I am in good health and that I had given a proposal form at the time of taking the policy
and that this declaration shall be the basis for the issuance of policy for the additional days requested
above and it will be subject to the standard terms and conditions and special clauses as applied to my
policy specifically.
With regards,

(Akshay Walvekar)
Signature and Name of insured.