EMPOWER INSURANCE GROUP
“A Valued Choice for Texas Drivers”
CANCELLATION REQUEST
Insured Name
Empower Policy #
Agent Signature
Date Signed
Time Signed
The undersigned agrees that:
The above referenced policy is lost, destroyed or being retained. No claims of any type will be made
against the Insurance Company, its agents or representatives, under this policy for losses which occur
after the date of cancellation shown above. Any premium adjustment will be made in accordance with
the terms and conditions of the policy. Cancellations will be processed the date received unless proof
of duplicate/replacement coverage or a bill of sale is provided. Request must be submitted the date
singed in order to honor that date.
Please check cancellation reason and provide required documentation as listed.
Additional documentation may be required at company discretion.
Application Upload in Error
Duplicate Coverage
- Copy of other carriers Dec Page
- Signature of Insured required
Non Sufficient Funds on Down Payment
- Copy of the Check Front and Back
- Signed Request to Cancel by Agent
Insured Never Took Possession
- Letter from the Dealership or Denial of Financing
- Signed Request to Cancel by Agent
Insured Request
- Signature of insured required
Insured Signature
Date Signed
Time Signed
Refund to: Agent Insured
Date of Cancellation:
