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Vani Vilas Road, Basavanagudi, Bangalore-560004 www.pnbmetlife.com Phone: +91-80-2643 8638. Fax: +91-80-41506969 DECLARATION OF GOOD HEALTH (Valid for 3 months from the signature date) Policy Number : Date Full Name of Policy Owner : Full Name of Life Insured : (If Different from Policy Owner) I wish to reinstate my above mentioned policy with PNB MetLife India Insurance Co. Ltd. Mobile no. (mandatory) Email ID Date: / / TO BE FILLED IN BY PNB METLIFE SERVICE PERSONNEL : Have the Signatures o.

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