Change Request Form

Name of the Policy Holder

Product Name

Policy Number

Policy Start Date

Policy End Date

Client ID

Enter Mobile Number

Enter Email ID

Branch Code

Policy Type

Change product

Change in Sum Insured (INR)

Change in Product (Migration)

Member Details

Sr No	Name of Insured Person	Date Of Birth	Existing Sum Insured (INR)	Desired Sum Insured (INR) *	Existing Deductible	Desired Deductible
No member data found. Please try again.

Existing Premium (INR)

Updated Premium of Desired Product (INR) *

Caller ID *

Health Declaration:Post commencement of the insurance policy with us, did any of the insured persons in the policy, including you if applicable, suffer from or have developed/suffered from any disease / illness / injury or accident / medical condition other than common cold or fever?

Yes

I accept and agree that:

I am Mr/Mrs/Ms. am an existing policyholder with Generali Central Insurance Co. Ltd. (formerly, Future Generali India Insurance Co. Ltd.) vide the policy number mentioned above.
Towards the proposal(s) made above, I am authorized to provide consent on behalf of all the persons named therein. Accordingly, I authorize Generali Central to consider the information existing in its official records, including the previous policy(s) details and past claim(s) history, for use in this proposal.
The relevant insured person(s) may have to undergo fresh medical check-up as a result of opting for (i) increase in sum insured and/or (ii) change in plan.
I shall comply with any other additional requirements raised, in writing, by Generali Central, including payment of additional premium towards risk loading, if any, within 15 days from the date of receipt of such written communication.
All the information provided by me, and on behalf of all the persons named above, are true and complete in all respects and no other information, relevant to the context of this proposal, has been suppressed or misrepresented.
Any non-disclosure or incomplete/ incorrect information may lead to nullifying of the insurance policy, if issued, or repudiation of claim or cancellation of the insurance policy, in line with the provisions of the corresponding Policy Wordings.

I have read and agree to the above Terms & Conditions