Insurance Reinstatement Request

INSURANCE REINSTATEMENT REQUEST

Applicant Name:

Applicant / Insured Information

Policy Information

Insurer Name:

Coverage Limit:    Deductible:

Premium Amount Due:    Policy Period: From to

Reinstatement Request Details

Date Policy Lapsed:

Coverage Selection for Reinstatement

Select coverage components to be reinstated (check all that apply):

Property / Structural Coverage

Liability Coverage

Medical Payments / Personal Injury Protection

Uninsured / Underinsured Coverage

Other (describe below)

Reason for Lapse and Supporting Documentation

Provide details of events, notices, or circumstances that led to lapse and attach supporting documents. If payment-related, indicate whether payment is enclosed or pending underwriting approval.

Proof of payment or payment arrangement

Medical records / exam results (if applicable)

Police or incident report (if claim-related)

Proof of insurability / underwriting statements

Other supporting documents attached

Beneficiary Designation (If applicable)

Primary Beneficiary Name:

Relationship:    Percentage:

Contingent Beneficiary Name:

Relationship:    Percentage:

Payment and Premium Arrangement

Payment Method:

Check / Money Order enclosed

Credit / Debit Card (authorize below)

Electronic Funds Transfer

Payment arrangement requested (subject to approval)

Representations, Authorization, and Certification

I certify that the information provided on this Insurance Reinstatement Request is true, complete, and correct to the best of my knowledge. I understand that reinstatement is subject to the insurer's review, underwriting requirements, and receipt of any owed premium or other conditions imposed by the insurer. Reinstatement will not be effective until accepted in writing by the insurer or its authorized representative.

I authorize the insurer and its representatives to obtain and review records and information (including medical, financial, and claims history) relevant to the underwriting and reinstatement review. I understand that misrepresentation, omission, or fraud may render the policy void or permit rescission of coverage and may result in denial of this request.

I agree that any reinstatement, if granted, may be effective as of the date specified above or another date determined by the insurer. I acknowledge that coverage may be limited for events that occurred during the lapse period and that new exclusions, waiting periods, or additional terms may apply.

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