(For Insurance Company Use Only)
Policy Number
Date
Policyholder/Owner Name
Street Address
City
State/Province
Postal/Zip Code
Contact Phone
Email Address
Insured's Name (if different from Owner)
Insured's Date of Birth
I, the undersigned Policyholder, hereby apply for the reinstatement of the above-referenced insurance policy(s), which lapsed due to non-payment of premium on or about
Date of Lapse
I understand that reinstatement is conditional upon payment of the following:
Overdue Premium(s): The total amount of premiums currently past due.
Interest: Interest accrued on the overdue premiums, if applicable, calculated from the date of lapse to the date of application.
Interest Rate (%)
Interest Amount
Other Fees/Charges
Description | Amount | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Total Reinstatement Amount Due
Payment Method
Check / Money Order Enclosed
Wire Transfer Initiated
Automatic Withdrawal Requested
(To be completed by the Insured Person)
The Insured must answer the following questions to confirm their continued insurability since the policy's lapse date.
Question | Yes/No | |
|---|---|---|
A. Health Changes: Since the date of lapse, have you consulted with, been diagnosed by, or received treatment from any physician, practitioner, or clinic? (Excluding routine checkups and common colds.) | ||
B. Hospitalization/Surgery: Since the date of lapse, have you been hospitalized, had surgery, or been advised to have surgery or a medical procedure? | ||
C. Weight Change: Since the date of lapse, has there been any unexplained weight loss or gain of 10 kilograms / 22 pounds or more? | ||
D. Pending Application: Do you currently have any insurance application pending with another company, or have you been declined for insurance coverage since the date of lapse? | ||
E. Occupation/Travel: Since the date of lapse, has there been any change in your occupation, dangerous activities (e.g., piloting, skydiving), or planned foreign travel outside of your country of residence? |
Details of "Yes" Answers
If you answered "Yes" to any question (A-E), please provide full details below (including dates, nature of illness/injury, names of treating physicians/facilities, and current status). Attach additional sheets if necessary.
Date | Nature of illness/injury | Name of treating physician/facility | Current Status | Upload File | ||
|---|---|---|---|---|---|---|
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
I/We hereby declare that all statements and answers given in this application are true, complete, and correctly recorded to the best of my/our knowledge and belief. I/We understand that any false or misleading information may be grounds for the rescission or denial of reinstatement.
I/We understand and agree that:
I/We authorize any physician, hospital, clinic, or other medical-related facility, insurance company, or other person or institution to provide the Insurance Company with any information concerning my/our physical or mental health, medical history, treatment, or application for insurance, as required for the evaluation of this reinstatement application. A photographic copy of this authorization shall be as valid as the original.
Policyholder/Owner Signature
Insured Signature (if different)