Group Health Insurance Reinstatement Application
Group/Employer Information
Group/Employer Name
Group Number
Employer Contact Name
Employer Email
Employer Phone
Employee/Member Information
Employee Name
Member ID
Date of Birth
Email
Phone
Coverage Details
Requested Effective Date of Reinstatement
Coverage Type
Employee Only
Employee + Spouse
Employee + Children
Family
Reason for Reinstatement
Declaration and Authorization
By signing below, I certify that the information provided is true and complete to the best of my knowledge.
Employee Signature
Date
Employer Signature
Date