Star Health and Allied Insurance Co. Ltd.

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Protorma Service Request Form

I requert you to kindly effet lhe following ch.ngeG)in the policy

! cmne"or"oo,"* Change of contact detail3

E ch.nse or or.upation

Corection in lnrur€d details (plea5e rlck ihe appropiate optionG))

CitY

Chant. ol contact det.ib :

Change in Occupation:

Correction i. htur€d Details:

N.me of th€ lnsured person

Olhe6lPlea5e specilv .nv oth€r Recunem€nl):

I hereby derl.re th.t th€ information provided aboE aretrue to the b.n of my knowledte.

' Pleas€,' nrandaloryi€ ds

FOR SRANCH USE ONI.Y