North Country Insurance Company

NORTH COUNTRY INSURANCE COMPANY REINSTATEMENT REQUEST FORM

NOTE TO AGENTS: Please read the following instructions carefully before submitting this form:

1. A check for the current premium balance due, which includes a Late Payment Fee, must accompany this form.

2. All Reinstatement Requests are subject to Company approval.

Agent Code: Agent:

Policy #: Insured:

I/We are hereby requesting reinstatement of the above policy, which was canceled on . I/We have not had any reportable losses since the date of cancellation to which this insurance would apply.

Insured Signature:______Date: ______

Agent Signature: ______Date: ______

For Office Use Only:

 REINSTATEMENT ACCEPTABLE:  REINSTATEMENT UNACCEPTABLE - Reason: ( SEE ATTACHED)

______

Signature of Underwriter:______

Date: ______

NCIC Ed. 07/14