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Request for Major Revival of Policy Form

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REQUEST FOR MAJOR REVIVAL OF POLICY

Post review of the Major revival form, client may have to undergo medical tests / physical examination (at his/her own cost). In case of Kotak Head Start Joint Life, details of Secondary Life to be filled in the policy holder's column.

Policy Number:

Client ID:

Life Insured:

Proposer:

Contact Number:

Mobile Number:

Email ID:

1) NAME OF:

Mr/Ms/Title

Surname

First name

Middle name

Life Insured Nationality:

Policy Holder Nationality:

2) Occupation Details – Life Insured / Proposer

a) Life Insured:







b) Proposer:







c) If Housewife, please specify source of income

3) Education Details – Life Insured / Proposer

a) Life Insured:


b) Proposer:


4) Name & Address of the Present Employer / Business

Life Insured:

Policy Holder (if different from Life Insured):

a) Designation:

b) Nature of work:

c) Annual income:

5) To be answered compulsorily

Answer Yes / No for Life Insured and Policy Holder

a) Is the occupation of the life insured/proposer associated with any specific hazards (which would render him/her susceptible to any injury or illness)?

b) Has there been any change in your occupation, Nature of job, avocation or place of residence since the date of signing the original application?

c) Is the life insured/proposer engaged in or intends to take part in any hazardous hobbies/activities (which would increase the risk of any injury or illness)?

d) Do you have any history of conviction under any criminal proceedings in India or abroad?

e) Are you a Politically Exposed Person?

If the answer to any of the above questions is YES, kindly give details below:

6) Personal Statement Regarding Health of Life Insured / Policy Holder

a) Height (cms)

b) Weight (kgs)

c) Any history of weight loss or weight gain in last 1 year?

If yes give details:

7) Since the Date of signing the original application, have you:

a) Consulted a Medical Practitioner for any ailment / injury requiring treatment for more than 7 days, or remained absent from work for more than 7 days, on health grounds or claimed against your health insurance policies?

b) Undergone any cardiological / pathological or radiological tests?

8) Since the Date of signing the original application, have you suffered from / are suffering from:

Please answer Yes / No for Life Insured and Policy Holder

a) High or low blood pressure, rheumatic fever, chest pain, myocardial infarction or any other disease or disorder of the heart or arteries?

b) Jaundice, anaemia, piles, ulcers, hernia, hydrocele, goiter, diabetes mellitus or any other disease of the stomach, liver, spleen, gall bladder or pancreas?

c) Asthma, bronchitis, pleurisy, tuberculosis or any other disease or disorder of lungs?

d) Paralysis, epilepsy, fits or any kind of nervous breakdown or any other disease related to the brain or the nervous system or arthritic, skeletal or joint disorders?

e) Any disease or disorder of ear, nose, eyes or throat, including defective sight or hearing or discharge from ears?

f) Cancer, leprosy, rheumatism, gout, enlarged glands or tumors?

g) Any disease or disorder of kidney, prostate, urinary system or reproductive system?

h) Does the life insured have any physical defect / deformity illness / impairment / disability not mentioned above?

i) Is the life insured or partner HIV positive or suffering from AIDS, hepatitis, gonorrhea, syphilis or any other venereal disease? Has the life insured or partner ever been tested for HIV/hepatitis?

j) Has the life insured ever had any accident requiring hospitalization or undergone any treatment or operation for any ailment not mentioned above?

k) Is the life insured pregnant now or has the life insured had any abortion or miscarriage or caesarean section after the date of the proposal? (For female lives only)

Sr. No. Nature of ailment / disease / condition etc Date of Diagnosis Fully recovered / still under treatment Name, Address and Telephone Number of treating doctor

9) Response compulsory

a) Has any proposal on your life / application for reinstatement been postponed, declined or accepted with extra premium or at modified terms by this company or any other insurance company?

b) Are there any existing policies, application for revival of lapsed Policy or fresh proposals on your life, under consideration of this Company or any other Insurer?

If yes, please give details below:

10) Additional details

Usage of following Life Insured Proposer Average usage per day Reasons for giving up
Current Past Current Past LI PR LI PR
Alcohol
Tobacco
Any Narcotics

Declaration by the Life Insured and Policyholder

I/We declare that I/We have answered the questions in this Policy Revival Form after fully understanding the nature of the questions and the importance of disclosing all information while answering such questions. I/We further declare that the answers given by me/us to all the questions in this form are true and complete in every respect and that I/We have not withheld any material information or suppressed any fact. I/We undertake to notify Kotak Life Insurance of any change in the state of health of the life insured or as to his/her occupation or any decisions about his/her existing policies or proposals subsequent to the signing of this form and before the acceptance of the risk by Kotak Life Insurance.

I/We further declare that this Policy Revival Form will also be the basis of the contract of insurance and if any untrue statement is contained in this form, the Company shall have the right to vary the benefits which may be payable and further if there has been a non-disclosure of a material fact the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company. I/We hereby authorise the employer, doctor or hospital of the life insured to divulge to the Company any information required by them in connection with the policy contract. I/We understand that the contract will be governed by the provisions of the Insurance Act, 1938 and that the contract will not commence until the Company's written acceptance of this application is received.

Date:

Place:

Signature / thumb impression of the Life Insured

Signature / thumb impression of the Policy Holder (if different from the life insured)

Declaration by the Person Filling in the Form

I, , having known the Policy Holder for a period of declare that I have explained the nature of the questions contained on this application to the Policy Holder.

I have also explained that the answers to the questions form the basis of the contract of insurance between the Company and the Policy Holder and that if any untrue statement is contained therein the Company shall have the right to vary the benefits which may be payable and further if there has been a non-disclosure of a material fact the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company.

Date:

Place:

Address of scribe:

Signature of scribe

Signature/Right thumb Impression of the Proposer as witness

Signature of Advisor/Broker

Notes

1. Policy can be revived post it’s discontinuance. The revival period would end after 2 years from the date of discontinuance or end of lock in period whichever is earlier.

2. Where the policy is accepted for revival the discontinuance charges deducted from the fund will be added back to the fund value and units of the segregated fund chosen by the policyholder will be allotted at the NAV as on the date of revival.

3. Post discontinuance if you want to revive the policy and same is in major revival then you will have to complete the major revival formalities.

4. This policy shall be revived only post fresh underwriting of the case and fulfillment of all requirements as may be called for by the Company.

5. Kindly note that the amount paid by you towards revival of your policy are lying unadjusted in your policy suspense account and your insurance cover will not be reinstated unless the requirements are fulfilled.

Guidelines to fill the Major Revival Form

A) Mandatory Fields include contact number, occupation/avocation/residence, education, personal details, medical questions, existing/applied policies and habits. If policy holder has signed in vernacular/thumb impression then scribe details are required.

B) Additional Information includes alterations, income proof documentation, NRI clients requirements, and cancellation/overwriting instructions.

Policy Number Acknowledgement:

Branch Name:

Date:

Time:

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What the Request for Major Revival of Policy Form Is

The Request for Major Revival of Policy Form is a formal submission used by a policyholder to seek reinstatement of a lapsed insurance policy after a major lapse event. It collects identifying information, the original policy number and insurer, the reason for lapse, proposed effective date, supporting evidence of insurability, and proposed payment or premium arrangements. Insurers use the submission to determine underwriting requirements, request additional documentation, or issue conditional acceptance. This document establishes the record for reinstatement and creates audit evidence of the revival request and insurer response.

Why a Proper Request Matters for Reinstatement

A complete, accurate request reduces processing delays, creates a clear audit trail, and documents consent and intent to revive coverage. Properly prepared forms ensure insurers can assess risk quickly and preserve the policyholder’s rights while meeting ESIGN and UETA requirements for electronic records and signatures where applicable.

Why a Proper Request Matters for Reinstatement

Who Typically Prepares and Receives the Form

This form is completed by policyholders, brokers, or authorized representatives and returned to the issuing insurer or their underwriting unit.

  • Policyholders and named insureds who request reinstatement following a lapse in coverage
  • Insurance agents or brokers submitting supporting documentation and premium arrangements
  • Third-party administrators or legal representatives with written authorization to act for the insured

The insurer’s underwriting or policy-services team reviews and documents the outcome; retain a copy for your records.

Critical Sections to Include on a Professional Request

A clear, professional request groups identity, policy details, reasons for lapse, evidence, payment terms, and declaration/signature blocks so insurers can process quickly and consistently.

Policy Details

Policy number, original effective and expiration dates, named insured and any additional insureds to match insurer records and avoid processing delays.

Lapse Reason

Concise description of the events leading to nonpayment or lapse, including relevant dates and any extenuating circumstances the insurer should consider.

Evidence of Insurability

Medical reports, inspection reports, loss history, or other underwriting evidence required to evaluate risk and determine whether additional underwriting conditions apply.

Requested Terms

Requested revival effective date and proposed premium payment method, including whether back premium, interest, or fees are to be paid with this submission.

Declarations

Clear attestations by the applicant regarding the accuracy of provided facts, authorizations for insurer inquiries, and consent to terms of conditional reinstatement.

Signature Block

Printed name, title for organizations, signature and date, and space for insurer acknowledgment; include witness or notary lines if state or insurer requires authentication.

Essential Data You Must Provide

Policy Number: Exact insurer policy number
Named Insured: Full legal name as on policy
Date of Lapse: MM/DD/YYYY format
Reason for Lapse: Short factual description
Premium Due: Amount or method stated
Contact Information: Phone, email, mailing address

Four Steps to Complete and Submit a Revival Request

Follow these sequential steps to prepare and deliver a complete request that insurers can process without unnecessary follow-up.

  • 01
    Gather documents: Collect policy, IDs, medical or repair records
  • 02
    Complete form: Fill fields exactly per instructions
  • 03
    Attach evidence: Include requested supporting documents
  • 04
    Submit to insurer: Send via insurer portal, email, or mail

How to Configure an Online Revival Request Workflow

Typical online workflows use templates, automated routing, signer authentication, and retention rules to streamline processing.

Field Configuration
Upload Template Use a fillable PDF or DOCX template
Signer Assignment Assign policyholder and agent roles
Authentication Method Email link plus optional SMS code
Retention Policy Auto-archive signed PDF/A with audit trail

Where a Completed Request Typically Flows

Knowing routing reduces uncertainty. Common destinations are underwriting, policy services, or the agent of record.

  • Agent Review: Broker verifies identity and attachments
  • Underwriting Intake: Underwriter evaluates evidence and risk
  • Decision Notice: Insurer issues conditional acceptance or decline
  • Policy Update: If accepted, policy is reinstated and records updated

Digital Submission and Platform Considerations

Use digital tools that preserve a tamper-evident audit trail and support required signer authentication.

  • File Formats: PDF and DOCX accepted
  • Authentication: Email, SMS, or advanced methods
  • Integrations: CRM and document storage supported

Timing, Deadlines, and Expected Processing

Processing times and deadlines vary by insurer and policy; note insurer instructions and state rules where applicable to avoid forfeiting revival options.

Submission Deadline:

Varies by insurer; file promptly

Underwriting Response:

Typically within insurer business days

Premium Payment Timing:

Back premium usually required on acceptance

Effective Date Rules:

Insurer policy determines backdating

Appeal Window:

Varies by insurer policy terms

Key Milestones in the Revival Process

Below are sequential milestones you can expect from submission to reinstatement; actual timing depends on insurer procedures and evidence provided.

01

Request Submitted

Form and attachments received by insurer intake

02

Underwriting Review

Underwriter assesses risk and requests clarifications

03

Conditional Offer

Insurer issues acceptance terms and premium due

04

Policy Reinstated

Insurer updates policy records on payment and acceptance

Common Mistakes That Delay Revival Requests

  • Missing or incorrect policy number prevents insurer from locating the file and causes immediate delays.
  • Failing to attach required evidence of insurability prompts underwriting re-requests and extends decision time.
  • Incomplete signature blocks or unsigned declarations lead to form rejection and require resubmission.
  • Submitting to the wrong department or using an unsupported file format can result in lost or unprocessed requests.

Consequences of an Incorrect or Late Request

Denial Risk: Revival may be refused
Higher Premium: Underwriting may increase rates
Coverage Gap: Periods without protection may persist
Backdated Terms: Insurer may apply exclusions
Administrative Fees: Fees may be charged
Tax Reporting: Premiums affect tax filings

Real-World Examples of Revival Requests and Outcomes

These examples show how organizations use structured forms and digital tools to manage revival workflows and evidence submission.

Martin Properties

Tim Martin processed revival requests fully online to reduce delays

  • Centralized signatures and secure uploads
  • As a result, the company improved turnaround and maintained continuous service for tenants while preserving audit records.

Fertility Centers of Illinois

John Butler standardized forms and electronic signatures for sensitive patient-related policies

  • HIPAA-focused workflow with signed authorizations
  • The center retained compliant records, reduced manual handoffs, and accelerated insurer confirmations.

eSignature Vendor Pricing Comparison for Completing Revival Requests

Selected vendors and plan-level starting prices are shown to help assess eSignature costs; signNow is listed first per comparison convention.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about validity, signing, authentication, and next steps for rejected or incomplete revival requests.


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