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Change Request Form

1. The document is a change request form for an insurance policy. 2. It allows the policyholder to request changes to their address, plan, sum insured, add or delete members, and other details. 3. The form requires information such as the policy number, name, new address, contact details, current and desired sum insured, member names and dates of birth, and reason for deletion.

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Kaushik Sarkar
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842 views1 page

Change Request Form

1. The document is a change request form for an insurance policy. 2. It allows the policyholder to request changes to their address, plan, sum insured, add or delete members, and other details. 3. The form requires information such as the policy number, name, new address, contact details, current and desired sum insured, member names and dates of birth, and reason for deletion.

Uploaded by

Kaushik Sarkar
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Change Request Form

Policy Number: Name of Proposer:


Please tick the appropriate box and fill the details in the corresponding section: 1. Change in Address 2. Change in Plan 1. New Address (Address proof to be enclosed) Name: Address Line 1: Address Line 2: District: City / Town: State: Contact Numbers Landline E-mail ID: Any change requested in contact details will be incorporated for all your policies with us. 2A. I want to opt for 2-year plan and avail 7.5% discount (Applicable for Easy Health Plan only) 2B. I want to Change my Plan to: Standard Floater Exclusive Individual Premium (please Tick) Mobile Pin code: 3. Change in Sum Insured 4. Member Addition / Deletion 5. Others

3. Change in Sum Insured

Name of Insured:
Existing Sum Insured: Desired Sum Insured: If Sum Insured Change is desired for more than one member, please use additional sheet to give information all. 4. Member Deletion

Name: Date of Birth: Relationship with proposer:


Reason for deletion: Deletion of Member : Please enclose a additional sheet for more than one deletion. For addition of any individual, fresh proposal form should be filled. 5. Others, please furnish details:

Gender:

Male

Female

D D M M Y Y Y Y

I/we accept and agree that: 1. I/ We may have to undergo fresh pre policy health checkup as a result of opting for (i) increase in sum insured and /or (ii) addition of critical illness rider and/ or (iii) Addition of insured member. 2. I/ We shall comply with any other additional requirements including payment of additional premium towards risk loading, if any, within 7 days from the date of such written communication received from AMHI 3. I/We authorize AMHI to renew the Policy under its existing terms and conditions if I/We fail to comply with either of the above stipulations Signature of Proposer/ Policy Holder: Certification in case the Proposer has signed in vernacular : (The below must be witnessed by someone other than the agent / employee of the company) The contents of this form and its particulars have been explained by me in vernacular to the Executant. Signature of the Proposer: Signature of the Witness: Date:

Name of Witness: Address: Contact Number:


Apollo Munich Health Insurance Company Ltd. reserves the right to accept/reject any changes requested. Certain changes may require additional premium, letters to this effect would be sent Enclosures: (if any) 1. 2. 3.

E-mail : customerservice@[Link] toll FREE : 1800-102-0333 [Link]

AMHI/CC/H/0047

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