The ACORD name and logo are registered marks of ACORD
POLICY NUMBER
CANCELLED POLICY INFORMATION
EXPIRATION DATEEFFECTIVE DATE
POLICY TERM
EFFECTIVE DATE AND
HOUR OF CANCELLATION
PM
AM
TIMECANCELLATION DATE
INSURED NAME AND ADDRESS
NAIC CODE:
POLICY TYPE
COMPANY NAME AND ADDRESS
AGENCY
CUSTOMER ID:
SUB CODE:CODE:
(A/C, No, Ext):
PHONE
PRODUCER
CANCELLATION REQUEST / POLICY RELEASE
DATE (MM/DD/YYYY)
This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act.
(Not applicable in NH per RSA 412:5 I)
DATETITLEAUTHORIZED SIGNATURE
POLICY RELEASE (Complete SIGNATURES section below)
CANCELLATION REQUEST
(Policy attached)
Any premium adjustment will be made in accordance with the terms and conditions of the policy.
under this policy for losses which occur after the date of cancellation shown above.
No claims of any type will be made against the Insurance Company, its agents or its representatives,
The above referenced policy is lost, destroyed or being retained.
The undersigned agrees that:
DATEWITNESS
DATEWITNESS
DATESIGNATURE OF NAMED INSURED
DATESIGNATURE OF NAMED INSURED
LOSS PAYEEMORTGAGEELIENHOLDER
(Not applicable in NH per RSA 412:5 I)
DATETITLEAUTHORIZED SIGNATURE
© 1988-2017 ACORD CORPORATION. All rights reserved.ACORD 35 (2017/05)
FOR AGENCY / COMPANY USE
New York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will be
suspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To avoid these penalties, you must
surrender your registration certificate and plates before your insurance expires. By law, we must report the termination of auto insurance
coverage to the Department of Motor Vehicles.
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EFFECTIVE DATE
POLICY NUMBER
COMPANY
SUBJECT TO AUDIT
PREMIUM CALCULATION
PRO RATA
SHORT RATE
FLAT
$
PREMIUM
RETURN
FACTOR
UNEARNED
$
PREMIUM
FULL TERM
METHOD OF CANCELLATION
OTHER (Identify)
(Complete below)
REWRITTEN
REQUESTED BY INSURED
NOT TAKEN
REASON FOR CANCELLATION
DATEPRODUCER'S SIGNATURE
NAME AND ADDRESS REQUEST / RELEASE DISTRIBUTION
FINANCE COMPANY
LIENHOLDER
LOSS PAYEE
COMPANY
MORTGAGEE
INSURED
LENDER'S LOSS PAYABLE
LOSS PAYEEMORTGAGEELIENHOLDER LENDER'S LOSS PAYABLE
LENDER'S LOSS PAYABLE
SIGNATURES
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