An application for relief under sub-section (4) of section 54 of the Act or for re-instatement of a policy under sub-section (5) thereof shall be made in writing within the time respectively required by those sub-sections and sent or delivered to the company or society, with which the policy in question was effected, at its head office, or at the place specified in the notice before forfeiture served under section 23 of the Industrial Assurance Act, 1923, and shall contain a statement setting out the policy number or numbers (if any) in question, the grounds on which the application is made, the date on which the serviceman began the performance of relevant service, the period, if known, for which the serviceman is required to perform relevant service, or, if he is no longer performing relevant service, the date on which he ceased performing relevant service.

An application for the extension of a period of protection under sub-section (7) of section 54 of the Act shall be made in writing within twenty-eight days from the serving of a notice pursuant to Regulation 5 hereof and sent or delivered to the company or society, with which the policy in question was effected, at its head office, or at the place specified in the said notice, and shall contain a statement similar to that required under the immediately preceding paragraph of this Regulation.

Any statement relating to a person's performance of relevant service contained in an application made under sub-sections (4), (5) or (7) of section 54 shall be verified in such manner, if any, as the company or society may reasonably require, including the production of a certificate of the kind referred to in sub-section (1) of section 60 of the Act.