Health Insurance Reinstatement Application
Personal Information
Full Name
Date of Birth
Policy Number
Address
Phone Number
Email
Policy Details
Type of Policy
Reason for Lapse
Date of Lapse
Health Declaration
Have you been diagnosed with any illness since the lapse?
Yes
No
If Yes, please provide details
Are you currently taking any medication?
Yes
No
If Yes, please specify
Declaration & Signature
Applicant's Signature
Date