I have left India as on , and I request you to issue me a policy effective as soon as possible, since post my travel from India there have been no contingencies/medical events & emergencies reported by me till date. Also I do not anticipate any medical situation in the policy period from to which can lead in claim and hereby declare that I am in a sound physical and mental health at the time of the purchase of this policy.

The reason, I could not purchase the insurance before traveling as I was busy with my travel preparations and exams.

Name:

Date: 27-12-2024

Nominee Details

Name:

DOB:

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