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The INSULAR LIFE Assurance Company, Ltd.
IL Corporate Centre, Insular Life Drive,
Filinvest Corporate City, Alabang, 1770 Muntinlupa City
Tel. No. 771-1818
Application for REINSTATEMENT/POLICY CHANGE
We hereby apply for reinstatement / policy change of Policy No. ______________________
Insured Name:
______________________
Applicant-Owner's Name:
________________________
Mailing Address:
______________________
Mailing Address:
________________________
____________________________________
______________________________________________
Agent's Code:_________________ Payment: Php_________________ OR #:_________________ Date paid:_________________
Documents Enclosed: Full Medical Examination Policy Contract Others(Please specify)______________________
Present Occupation
Insured/Owner
Occupation
Nature of Work
Company Name & Address
___________________
___________________
______________________
___________________
___________________
______________________
___________________
___________________
______________________
___________________
___________________
______________________
That since the issuace of said Policy, I/we HAVE NOT: a.) received any threat on my/our life/lives; b.) been a party to any
administrative/civil/criminal case; c.) made any application for life, accident or sickness insurance or for reinstatement
thereof which has been declined, postponed or modified in kind, rating; and that I/we HAVE NO pending application for life insurance.
For exception/s, pls specify.________________________________________________________________________________
That within the next twelve (12) months I/We DO NOT intend to: a.) change my / our occupation/s;
b.) work or reside outside the Philippines; c.) become member/s or the Armed Forces or Police Force.
For exception/s, pls specify.________________________________________________________________________________
That I/We HAVE NOT made during the past two (2) years, NOR do I/We instend to make within the next twelve (12) months,
any aerial flights other thatn that as paseenger/s on scheduled commercial airlines.
For exception/s, pls specify.________________________________________________________________________________
I/We hereby represent that each of the foregoing statements written in PART 1 of this form are true and correct and that I/We have fully stated all exceptions to each of the statements and that if no exceptions are listed in the blank space provided for such exceptions, it shall have the same force and effect as if the word “NONE” were written therein.
I/We agree that any payment made in connection with this application shall be considered as a deposit only and shall not bind the company until this application is finally approved by the company during my/our lifetime and good health. If this application is disapproved, I/We also agree to accept the refund of all payments made, without interest.
I/We understand that the statements in this application shall form part of this life insurance contract. I/we further understand that for reinstatement cases, the policy shall be contestable wihin two years from the approval of reinstatement application, for fraud, concealment or misrepresentation of any material information.
DONE at _________________________________________________ this ____________________ day of __________, 20______.
______________________________
______________________________
______________________________
Signature of Witness/Agent
Signature of Payor / Applicant - Owner
Signature of Insured
______________________________
______________________________
Signature of Irrevocable Beneficiary
Signature of Assignee
NOTE: THE COMPANY MAY, AT ITS DISCRETION, DENY THIS APPLICATION OR REQUEST THAT APPLICANT/S TO FURNISH ADDITIONAL EVIDENCE OF INSURABILITY.
FOR HOME OFFICE USE ONLY
Approved by: _____________
Office: _____________
Date: _____________
HOME OFFICE ENDORSEMENT:
NO.____________________
AUTHORIZATION TO RELEASE RECORDS AND INFORMATION
To whom it may concern:
I, in my personal capacity or as legal guardian of ____________________, authorize any person, insurance company, or entity to give Insular Life or its authorized representative all requested records and
information of my or ______________________hospitalization, consultation or treatment in its custody, and needed as requirements for my reinstatement/policy change application and/or for any transaction
involving my insurance policy. A photocopy of this authorization shall be valid as the original.
________________________________
________________________________
Printed Name and Signature of Applicant - Owner
Printed Name and Signature of Insured
The INSULAR LIFE Assurance Company, Ltd.
IL Corporate Centre, Insular Life Drive,
Filinvest Corporate City, Alabang, 1770 Muntinlupa City
Tel. No. 771-1818
REVIVAL NOTICE _____________ Date
Dear Policyholder/s:
You will be happy to learn that your application for the reinstatement of your policy has been approved.
To assure yourself and your loved ones of continued protection under your policy, we urge you to remember your succeeding due dates so that you can
pay your premiums on time.
Policy Number
Mode
Next Premium Due Date
Premium
For this particular premium, this letter serves as your Premium Notice which you can present when you make your payment.
The INSULAR LIFE Assurance Company, Ltd.
