Date: 01-SEP-2015

Place: Pune

To,

The Manager, Bajaj Allianz General Insurance Company

Office: _________________

Subject: Extension of policy

Reference: Insured Name: __Akshay Dattatraya Walvekar__

Policy Number: __OG-16-9906-9910-00018746__

Policy period: from __05-AUG 2015______to __03 SEP 2015______

Date of Birth: __05-APR-1991________ Age: __24_____________

Dear Sir.

I hereby declare that I am in Good Health and that no event has occurred which can give rise to any claim in my earlier policy period mentioned above

I request that my policy be extended further for ___267___ days so that the total duration of cover for me overseas would be ____298_____days upto ___30th May 2016______.

The past history of any illness / disease /ailment / treatment / consultations is as follows :

____None_________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

I reconfirm that I am in good health and that I had given a proposal form at the time of taking the policy

and that this declaration shall be the basis for the issuance of policy for the additional days requested

above and it will be subject to the standard terms and conditions and special clauses as applied to my policy specifically.

With regards,

(Akshay Walvekar)

Signature and Name of insured.