<p> NORTH COUNTRY INSURANCE COMPANY REINSTATEMENT REQUEST FORM</p><p>NOTE TO AGENTS: Please read the following instructions carefully before submitting this form:</p><p>1. A check for the current premium balance due, which includes a Late Payment Fee, must accompany this form.</p><p>2. All Reinstatement Requests are subject to Company approval.</p><p>Agent Code: Agent: </p><p>Policy #: Insured: </p><p>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.</p><p>Insured Signature:______Date: ______</p><p>Agent Signature: ______Date: ______</p><p>For Office Use Only:</p><p> REINSTATEMENT ACCEPTABLE:  REINSTATEMENT UNACCEPTABLE - Reason: ( SEE ATTACHED)</p><p>______</p><p>Signature of Underwriter:______</p><p>Date: ______</p><p>NCIC Ed. 07/14</p>