Motion for reinstatement 2026

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4.8 out of 5

166 votes

The document is a Reinstatement Request Form for Active Health Plan coverage, allowing participants to request reinstatement for themselves and their dependents. It requires completion and submission along with payment to the specified address. Additional steps are needed for HMO plan members if 90 days have passed since last eligibility. The form must be signed by the participant, and reinstatement is effective upon receipt of payment and form, with no retroactive coverage.

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Click ‘Get Form’ to open the motion for reinstatement in the editor.
Begin by entering your Participant Name and MPID in the designated fields. This information is crucial for identifying your account.
Indicate the Payment Enclosed amount. Ensure that you include a check or money order for the remainder of your eligibility period.
Provide your phone number, ensuring it is accurate for any follow-up communications.
List all dependents you wish to reinstate, including spouses if applicable. This section is vital for ensuring coverage extends to all necessary individuals.
Optionally, provide a reason for your reinstatement request in the designated field.
Review the statement regarding coverage reinstatement and ensure you understand that it will not be retroactive. Sign and date the form at the bottom.

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2013	4.8 Satisfied (166 Votes)

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Motion for reinstatement 2026

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