Prudential Veteran'S Group Life Insurance - Application For Reinstatement Of Coverage Page 2
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1
2
3Veterans’ Group Life Insurance
Application For Reinstatement Of Coverage
Office of Servicemembers'
Control Number:
Group Life Insurance
Lapse Date:
D D
M M
Y
Y
Y
Y
Apply for reinstatement online at:
,
Coverage Amount:
Reinstatement Amount:
.
,
Must equal 3 months premium
1
VETERAN INFORMATION
First Name:
MI:
Last Name:
Address 1:
Address 2:
City:
State:
ZIP Code:
Country:
Phone Number:
Email:
You must check this box when the address is outside the United States.
2
CERTIFICATION OF HEALTH
(Use Section 2 only when your Lapse Date is less than 6 months ago. Use Section 3 if your
Lapse Date is longer than 6 months ago.)
I am applying for reinstatement of my insurance in the amount shown above. As a condition to the reinstatement of this
insurance, I certify that to the best of my knowledge and belief, I am now in as good health as I was on the date of the
insurance lapse.
SINCE THAT DATE, I have not been ill or suffered or contracted any disease, infirmity, or any injury, nor have I been prevented
by reason thereof from attending to my usual occupation, nor have I consulted a physician, surgeon, or other practitioner for
medical advice or treatment at home, hospital, or elsewhere in regard to my health, except as shown below. This statement
refers to all disabilities including any service-connected disabilities.
EXCEPTION: Describe any illness, disease, injury or medical treatment with dates since the lapse date. Also, give the names
addresses of all doctors, other practitioners and /or hospitals concerned. Please use remarks below for details.
Remarks:
I declare that, to the best of my knowledge and belief, the above statements are complete and true. Any deception or false
statement, either by reference, omission, or otherwise can result in loss of coverage or denial of a claim for benefits.
X
Date:
Veteran’s Signature:
D D
M M
Y
Y
Y
Y
*180B001*
GL.2010.019 Ed. 12/2012
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