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I (we) have no knowledge of, or reason to anticipate, any damage, loss, or claim and am (are) not aware of, nor should be aware of, any accidents, incidents, facts or circumstances that may result in future claims arising out of my ownership, operation or maintenance of the craft listed on Policy\\#   , since 12:01 A. M. on (Cancellation date) . I (we) agree that any loss, claim, damage or incident that occurred between the two dates listed above, will not be covered by this insurance policy.  \nPlease check the appropriate box below to pay the balance due: Enclosed is a check / money order payment in full to SkiSafe.  \nCharge to (Visa, Mastercard, or Discover) credit/debit card number:  \nCredit/Debit Card \\#  Expiration Date  By electronic check: ABA Routing \\#   Acct \\#:   Checking  Savings  Corporate   \nState law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.  \nAvoid policy cancellation for non-payment by enrolling in SkiSafe EZ Pay and we will automatically process your premium payment each year via the payment method you selected above.  \nEnroll in EZ Pay  \nby checking this box I agree to the following terms of use:  \nI authorize SkiSafe to enroll me in EZ Pay and to charge my insurance premium for this policy directly to my debit card, credit card or checking account as I have indicated above. I authorize SkiSafe to charge renewal insurance premiums and future balances from changes I make until I unsubscribe from the EZ Pay service. I understand that SkiSafe and/or my financial institution can cancel my enrollment in EZ Pay at any time. SkiSafe will make refunds, if any, as may be required by the financial institution involved.  \nSIGN HERE X   (Signature Required)  \nMailing Address   Home Phone\\#  Email Address  Cell Phone\\#    \nPlease complete & return this form via photo or scan/email to [customer@skisafe.com](customer@skisafe.com)  \nSkiSafe  \nOne Hollow Lane  \nLake Success, NY 11042  \n[www.skisafe.com](www.skisafe.com)","cbCaiezMKOi5QrGy","https://ap.wps.com/l/cbCaiezMKOi5QrGy","pdf",616701,"English","# NO KNOWN LOSS LETTER REINSTATEMENT REQUEST\n## Policy reinstatement declaration\n## Payment options and EZ Pay enrollment","[{\"question\":\"申请人需要在表格中做哪些声明？\",\"answer\":\"申请人需声明自己不知晓或无理由预见任何损失、损害或索赔，以及可能导致未来索赔的事故或相关情形，并确认取消日期到复效请求日期间发生的事件不在本保险覆盖范围内。\"},{\"question\":\"该表格如何办理余额支付？\",\"answer\":\"表格要求在下方选择支付方式：可以附上支票或汇票全额支付给SkiSafe，也可以选择信用卡/借记卡方式并填写卡号与到期日。\"},{\"question\":\"什么是EZ Pay，申请人需要同意什么？\",\"answer\":\"EZ Pay用于授权SkiSafe按申请人指定的支付方式在每年自动处理保费及后续余额扣款，并说明SkiSafe或金融机构可能随时取消授权；如适用还会按要求提供退还。表格要求签名并可勾选参与。\"}]","NO KNOWN LOSS LETTER REINSTATEMENT REQUEST - Payment and EZ Pay Enrollment Form | PDF",1789506931]