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Application For Reinstatement Fillable

This document is an application for reinstatement of a life insurance policy. It requests information to reinstate coverage, including details about the policy owner and insured. It asks health questions to determine insurability and eligibility for reinstatement. The applicant must sign declaring the information is true and complete, and agreeing the policy may be rescinded if any material facts are withheld.

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94 views1 page

Application For Reinstatement Fillable

This document is an application for reinstatement of a life insurance policy. It requests information to reinstate coverage, including details about the policy owner and insured. It asks health questions to determine insurability and eligibility for reinstatement. The applicant must sign declaring the information is true and complete, and agreeing the policy may be rescinded if any material facts are withheld.

Uploaded by

New Boss
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application For Reinstatement

Policy Number: _______________ Date: ____________________

Important
Failure to pay your premiums on time will result to the cancellation of your Policy and thus forfeiture of all benefits thereunder. To apply for reinstatement of
your Policy, simply accomplish the form below and submit it together with the payment of amount(s) due.

A. LIFE INSURED INFORMATION


Name

Last Name First Name Middle Name


Landline Number Mobile Number E-mail Address

Mailing Address

B. POLICY OWNER INFORMATION (If other than the Life Insured)


Name

Last Name First Name Middle Name


Landline Number Mobile Number E-mail Address

Mailing Address

DECLARATION OF INSURABILITY

1. Has the Life Insured ever had consulted, sought treatment for or been confined for diabetes, For any YES answers, please give complete details in the space provided below
high blood pressure, stroke, kidney disease, liver disease, cancer, leukemia or any blood
disorder, or other diseases not mentioned? Policy Owner Life Insured
Yes No Yes No

2. Does the Life Insured expect to change occupation or country of residence?

Yes No Yes No

3. Is the Life Insured currently taking any medication or undergoing any medical
treatment for any ailment?
Yes No Yes No

4. Has the Life Insured been advised hospital confinement, taken any diagnostic test or
undergone any medical or surgical treatment?
Yes No Yes No

5. Does the Life Insured engage or intend to engage in any private flying, diving, motorcycle,
car, motorboat racing or any other extreme sports or hazardous activities?

Yes No Yes No

6. For female Life Insureds, are you currently pregnant? If so, how many months?
Yes No __________ months

7. Life Insured’s Current Height _____________ ft/inches/cm Weight _____________ lbs/kilos


(Should you need more space, please use the back of this form and affix your signature.)

I hereby declare, to the best of my knowledge that the above answers relating to the Life Insured (and to the Policy Owner, if the Policy being reinstated
includes a Payor’s Death Benefit Rider) are true, correct and complete and that I have not withheld any material fact that may influence the assessment or
acceptance of this application.

I agree that this will form part of the Policy when approved by the Company and that failure to disclose on my part any material fact known to me may cause
the Policy to be rescinded.

Signature over Printed Name of Policy Owner Signature over Printed Name of Life Insured
(If other than the Policy Owner)

BDO Life Assurance Company, Inc.


BDO Corporate Center, 7899 Makati Avenue, Makati City, Metro Manila, Philippines
Customer Care Hotline: (632) 8885-4110 | Fax (632) 5325-0792 | Toll Free No. 1-800-1888-6603

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