The Customer Relations Officer,
____________ (Insurance Company Name),
Date: __/__/____ (Date)
Subject: Request for a penalty waiver
I would like to state that my name is __________ (Name) and I carry a __________ (medical/ vehicle/ life – Mention) insurance policy of your company ___________ (Company Name) from last ____________ (months/ years – Duration) having policy number __________ (Policy Number).
I regret to inform you that a payment of Rs. _______ (Amount) for _________ (monthly/ Quarter/ Annual) cycle was due on __/__/____ (Date) but due to the reason _______________ (Reason: unavailability of funds/ Out of town/ Forgot), I failed to pay the above-said installment. I have always paid the installments on time.
It would be humble if you kindly consider this as a genuine reason and accept my sincere apology. I request you to kindly waive the penalty applicable for the delayed amount of payment. I will make sure this will never be repeated and the current pending installment will be done by __/__/____ (Date).
____________ (Contact Number)
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