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How to fill out the Supplement to Statement of Facts for Retroactive Coverage Restoration
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Click ‘Get Form’ to open it in the editor.
Begin by entering your case name and case number at the top of the form.
In the section regarding your present circumstances, confirm that the statements are true and correct by filling in the date you signed the original Statement of Facts.
Specify the months for which you are requesting retroactive coverage restoration. If there are no changes, write 'No change' in the designated area.
Detail any differences in circumstances, including income, work expenses, and personal property. Be sure to provide documentation if required.
Indicate your California residency status and any changes in other insurance coverage by checking 'Yes' or 'No' as applicable.
Sign and date the form at the bottom. If someone is acting on your behalf, ensure they sign as well.
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