Critical Illness Insurance Reinstatement Form
Policyholder Information
Full Name
Policy Number
Date of Birth
Phone Number
Email
Address
Policy Details
Date of Policy Lapse
Reason for Lapse
Has there been any medical diagnosis or treatment since lapse date?
No
Yes
Health Declaration
Please provide details of any new or changed medical conditions:
Are you currently under any medical treatment?
No
Yes
If yes, provide details:
Declaration & Signature
I declare that the information provided above is true and complete to the best of my knowledge.
Signature
Date