Mailing Address: CoventryOne Member Services

Attn: CoventryOne Billing and Enrollment

P.O. Box 31210
Tampa, FL 33631-3210

Toll Free Fax Number: (877) - 899 - 6447

Toll Free Voice Number: (877) - 849 - 9690

REQUEST FOR REINSTATEMENT FORM

PLEASE NOTE: Once completed this form must be mailed to CoventryOne, Attn: CoventryOne Billing and Enrollment,
P.O. Box 31210, Tampa, FL 33631-3210. Upon receipt of this form along with a certified payment (cashier’s check
or money order) your account will be reviewed. All reinstatements must first meet eligibility requirements and be
approved by the CoventryOne designated panel. Reinstatement is not guaranteed and can take up to 45 days
to process. Per market guidelines, business checks may not be accepted.

Policyholders Name:

Policy Number/Case Number:

By signing this form and requesting reinstatement of my policy, I attest to the fact that I have not, nor any
member of my family has not incurred any change of my/their health status.

Policyholders Signature: Date:

Signature Needed to process reinstatement

Form and certified payment must be received by date on letter.

CURRENT BANKING INFORMATION FOR ACTIVE EFT MEMBERS

If your premiums are being drafted out of your account, please provide us with your current banking
information to make sure we have the correct account on file. Business accounts may be accepted for
individual policy’s according to state guidelines.

Account Number:_____________________________________ 9-Digit Routing Number: l___l___l___l___l___l___l___l___l___l

Name of Bank: ___________________________________ Name of Account Holder: ____________________________________
Relationship of Account Holder to the Primary Applicant:  Self  Spouse  Other ____________________
Permanent Address of Account Holder: ______________________________________________________________________________

Applicable premium amount is automatically withdrawn from the account provided on the 5th calendar day of each current coverage month,
or the next business day.
If your premium payment is returned unpaid, a Return Check Fee amount will be assessed in the amount of $20.00. The Account Holder
hereby authorizes CoventryOne to collect the premium payment due, including the Return Check Fee amount, via electronic funds transfer
(EFT) or automatic withdrawal from the account identified and provided herein or then current.
By signing below, I authorize CoventryOne to initiate automatic withdrawal of applicable premium payments from the account listed above.
I, the Account Holder, acknowledge and understand that it is my responsibility to notify CoventryOne Member Services, should the
payment information provided change while a policy of coverage remains in force and effect.
I agree this authorization will remain in effect until I provide written notification terminating this service. This request must be received
before the last business day of the month before the automatic debit transaction (the transaction will occur on the 5th of the month, or next
business day).

Account Holder Signature:_______________________________________________________ Date:_________________________

Authorized signature for bank account
Print Name:_____________________________________________________________ Phone No.:___________________________