Insurance Reinstatement Document

INSURANCE REINSTATEMENT DOCUMENT

Policy Number:    Insurer Name:

INSURED INFORMATION

POLICY DETAILS

Property   Liability   Auto   Life   Other:

Policy Period From:   To:

COVERAGE TO REINSTATE

Select coverages to be reinstated (if approved):

Liability Coverage   Property Coverage   Collision Coverage   Comprehensive Coverage   Medical Payments   Uninsured/Underinsured Motorist

REINSTATEMENT REQUEST DETAILS

Date Policy Lapsed:    Reason for Lapse:

Payment of past due premium   Evidence of insurability   Completion of required repairs   Other:

Check   Credit Card (last 4 digits: )   ACH/Bank Transfer   Other:

DOCUMENTATION CHECKLIST

The undersigned submits the following documents in support of this reinstatement request (check all provided):

Proof of insurability/medical information   Medical exam report   Police report (if applicable)   Photographs of damage/property   Repair estimates/invoices   Signed authorization to obtain records

BENEFICIARY INFORMATION

EXCLUSIONS AND PRIOR LOSS DISCLOSURE

DECLARATIONS, AUTHORIZATIONS AND CONDITIONS

By submitting this reinstatement request, the Insured certifies that the information provided in this document is true, complete, and correct to the best of the Insured's knowledge. The Insured acknowledges that any material misstatement, omission, or fraudulent representation may void coverage or subject the Insured to rescission of the policy. The Insured authorizes the insurer and its representatives to obtain and review medical, claim, credit, employment, and other relevant records as may be necessary to evaluate this request.

The Insured understands that reinstatement, if granted, will be effective only upon acceptance by the insurer and completion of any stated conditions. Coverage is expressly conditional on payment of any required past due premium and compliance with underwriting requirements. No coverage is in effect until the insurer issues written notice of reinstatement or an effective date is otherwise confirmed in writing by the insurer.

AGENT / PRODUCER INFORMATION

Certification: I hereby request reinstatement of the policy identified above and acknowledge that reinstatement is subject to the insurer's review and approval of all submitted information and documentation. I agree that the insurer may rely on the statements and representations contained herein in determining eligibility for reinstatement.

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