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Change Request form NEW

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27 views

Change Request form NEW

Uploaded by

ayankum9865
Copyright
© © All Rights Reserved
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
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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 Tenure  3. Change in Sum Insured  4. Member Addition/ Deletion  5. Change in Product  6. Others 
I want to opt for a) Protector Rider^  b) Individual Personal Accident Rider* c) Hospital Daily Cash Rider^ with Sum Insured: ` 1000 per day  ` 2000 per day  ` 3000 per day 
* Sum Insured under Individual Personal Accident rider will be 5 (five) times the Sum Insured of Optima Restore (Base Plan) upto a maximum of Rs. 1 Crore and this rider will be offered only to the Proposer. ^Pro-
tector Rider and Hospital Daily Cash Riders will be offered on individual sum insured basis if the base plan is on individual sum insured basis or floater sum insured basis if the base plan is on floater sum insured
basis. Protector Rider and Hospital Daily Cash Riders will be available on all or none basis.
I want to add a to my health Insurance. Yes  No 
1. New Address (Address proof to be enclosed)
Name : (Mr./ Ms./ Mrs.)
Address :

City/ Town :
District : State :
Pin Code : Mobile :
Telephone : E - Mail :
2A. I want to opt for 2-year plan  2B. I want to opt for 1-year plan 
3. Change in Sum Insured
Name of Insured:
Existing Sum Insured: Desired Sum Insured:
4. Member Deletion/ Addition
Name of Insured:
Date of Birth D D M M Y Y Y Y Gender Male  Female 
Relationship with proposer:
Reason for deletion:
For addition of any individual, fresh proposal form should be filled.
5. Change in Product
Name of Insured:
Existing Product: Desired Product:
Desired Sum Insured/ Deductible
Desired Plan Variant
(in case of Optima Plus product):
Individual/ Floater Height/ Weight*
* To be filled only incase Insured shifted from Optima Cash Product
Note: Please enclose an additional sheet for change in sum insured/ change in product for more than one member
Health Status Declaration : Post commencement of your insurance policy with us, did you suffer from or are currently suffering from or have developed any disease/
illness/ injury or accident/ medical condition other than common cold or fever? Yes No
If answer is yes, please provide all the relevant documents/ information including but not limited to Doctors prescription, Medical Test Reports etc.
Please note: Any Non Disclosure or Incomplete/ incorrect/ partially correct information may lead to repudiation of claim or cancellation of policy as per policy terms and conditions.
If Sum Insured Change is desired for more than one member, please use additional sheet to give information.
(Applicable for Easy Health, Optima Restore, Optima Plus, Maxima, Optima Senior, Optima Cash, Individual Personal Accident Product.)
6. Others, please furnish details:

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 advantage rider/ critical illness rider and/
or (iii) Addition of insured member/ change in product.
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 HDFC ERGO General Insurance Company Ltd.
3. I/ We authorize HDFC ERGO General Insurance Company Ltd. to renew the Existing Policy under its existing terms and conditions if I/ We fail to comply with either of the above
stipulations”
4. I hereby declare and warrant that on my behalf and on behalf of all the insured that all the information provided above are true and complete in all respect and no other information
which is relevant in the context has been supressed.
Signature of Proposer/ Policy Holder: Date:
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:
Name of Witness:
Address:
Contact Number:
HDFC ERGO General 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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. For more details on the risk factors, terms and conditions, please read the sales brochure/ prospectus before concluding the
sale. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.

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