Insurance Application for Reinstatement

Insurance Application for Reinstatement

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details

Policy type: Life Health Property Other

Coverage amount:   Deductible:   Premium:

Policy period: From to

Coverage Selection & Options

Select coverages to be reinstated: Property damage Liability Medical payments Collision Other (describe below)

Exclusions and Acknowledgements

I acknowledge that reinstatement is subject to the insurer's underwriting review and that standard policy exclusions apply. Approval of this application may be conditioned upon payment of overdue premiums, completion of underwriting requirements and satisfactory evidence of insurability. The insurer's written confirmation is required before coverage is reinstated; oral statements or payments do not constitute acceptance.

I have read and understand the insurer's standard exclusions and the conditional nature of reinstatement.

I authorize the insurer to obtain medical records and other relevant information for underwriting purposes.

I authorize the insurer to obtain financial and payment history records relevant to this reinstatement request.

Evidence of Insurability & Documentation Checklist

Documents submitted with this application: Recent medical report / physician statement Proof of payment of outstanding premium Bank statement or payment history Prior policy declarations or schedule Other (describe below)

Beneficiary Information

Relationship:   Percentage:

Relationship:   Percentage:

Health and Underwriting Questions

1. In the past 12 months, have you been treated for, diagnosed with, or advised to obtain treatment for any illness or condition not previously disclosed?

2. Have you used tobacco, nicotine products or e-cigarettes in the past 12 months?

3. Are you currently taking any prescription medications?

Certification and Authorization

I certify that the statements and answers in this application are true, complete and correctly recorded to the best of my knowledge. I understand that any material misrepresentation or omission may be grounds for denial of reinstatement or rescission of coverage in accordance with the policy terms and governing law.

I agree that the insurer may rely upon this application and any supplemental information to determine eligibility for reinstatement. I understand that coverage will not be reinstated until the insurer issues written acceptance, which may be conditioned upon payment of any past due premium and receipt of satisfactory evidence of insurability.

I authorize any physician, medical practitioner, hospital, insurance company or other entity to release to the insurer any information requested for underwriting, claim or reinstatement review. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

I acknowledge that I have read and understand the statements above and that I will promptly notify the insurer of any material changes in health, occupation, or other facts prior to issuance of written reinstatement acceptance.

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