Prudential Veteran'S Group Life Insurance - Application For Reinstatement Of Coverage Page 3
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1
2
3Veterans’ Group Life Insurance
Application For Reinstatement Of Coverage
Apply for reinstatement online at:
Office of Servicemembers'
Group Life Insurance
Control Number:
Last Name:
3
CERTIFICATION OF HEALTH
(Use Section 3 only if your Lapse Date is more than 6 months ago. Use Section 2 if your
Lapse Date is less than 6 months ago.)
Height:
feet
inches
Weight:
pounds
Have you had or been treated for or had known indications of:
Y
N
Y
N
A. Heart trouble or abnormal pulse?
F.
Disorders of kidney, bladder or urinary system?
B. High blood pressure?
G. Disorders of the liver or gall bladder?
C. Diabetes or sugar in urine?
H. Disorders of stomach or intestines?
I.
Arthritis?
D. Cancer or tumors?
E. Lung or respiratory disorders?
In the past 5 years have you:
N
Y
N
Y
J. Been declined or postponed for any form of life or
O. Used barbiturates, heroin, opiates, or other
health insurance or offered a policy with a higher
narcotics, or been treated for alcoholism?
premium because of health reasons only?
P. Been diagnosed as having Acquired
K. Been absent from work for more than 5 continuous
Immunodeficiency Syndrome (AIDS)
days because of sickness or injury?
or AIDS-related complex (ARC)?
L. Been advised to have a surgical procedure?
Q. Had any known physical impairments,
deformities, or ill health not covered above?
M. Been a patient or been advised to enter a
hospital or health care facility?
R.
Do you have a service-connected disability?
N. Consulted, been attended, or examined by a
doctor or other practitioner other than annual
If yes, what is the VA claim file number?
or periodic physicals?
Please provide details for all questions answered “yes.” Use additional paper if necessary.
Question
Nature of
Illness began
Time lost from
Full Recovery
Treating Physician’s
Number
Illness
Month/Year
Normal Activities
Month/Year
Name & Address
(Please attach a separate sheet with details for any question answered “yes”)
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
*180B002*
GL.2010.019 Ed. 12/2012
28607-1112
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