Date:

Place:

To,

The Manager,
Future Generali India Insurance Company Limited
Office: _________________

Subject: Request for cancellation of (Health / Personal Accident) policy and No Claims
declaration
Proposer Name: ___________________________________
Policy Number:__________________________________
Policy period: from ______________to ______________

Dear Sir/Madam,

I request that my policy be cancelled with effect from__dd/mm/yyyy__. I hereby declare that, I have
not claimed and will not claim further under above mentioned policy.

With regards,

Signature and Name of Proposer.