Policy Servicing Request Form - Health Plans-1 (Page 2 of 2) in pdf

FREE LOOK CANCELLATION

General Rules:

1. Free look cancellation request should be submitted within 15 or 30 days (as mentioned in your Policy document) from the date of

receipt of the Policy document. 2. Free look cancellation charges as specified in the Option to Return clause in your Policy document will

be deducted. 3. Please submit the NEFT mandate along with an original cancelled cheque with this request.

I would like to exercise the Free Look Cancellation option for the above Policy, as I do not agree to the terms and conditions.

Reason:

______________________________________________________________________________________________________________

I am returning the original Policy document along with this request. Please refund the premium paid by me after deducting the applicable free look

cancellation charges.

FREE LOOK CANCELLATION (CHANGE OF PLAN)

General Rules:

1. Free look cancellation request should be submitted within 15 days or 30 days (as mentioned in your Policy document) from the date of

receipt of the Policy document. 2. Free look cancellation charges as specified in the Option to return clause on your Policy document will be

deducted. 3. The differential amount, if any has to be paid along with the application for the new plan. 4. Please submit the new proposal

form, illustration and other required documents. 5. Acceptance of the new proposal is subject to underwriting. (where applicable)

I would like to change my plan from _____________________________ to _____________________________ under the Free Look Cancellation option.

I am submitting the documents mentioned below along with this request.

Original Policy Document

New Proposal Form

New Illustration

Others (Please specify):_________________

SIGN HERE

Date:

Place:

Signature of the Policyholder

For queries or more information, call us on 1860-267-9999 (Local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available all days

from 9 am to 9 pm | Email -

|NRI

(For NRI customers only)

| Visit -

Communication Address: 14 Floor, Lodha Excelus, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai – 400011.

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Policy Servicing Request Form - Health Plans-1 Page 2