Fillable CANCELLATION REQUEST / POLICY RELEASE (Standard Lines Services)

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CANCELLATION REQUEST / POLICY RELEASE (Standard Lines Services)

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INSURED
MORTGAGEE
COMPANY
LOSS PAYEE
LIENHOLDER
FINANCE COMPANY
REQUEST / RELEASE DISTRIBUTIONNAME AND ADDRESS
PRODUCER'S SIGNATURE DATE
REASON FOR CANCELLATION
NOT TAKEN
REQUESTED BY INSURED
REWRITTEN
(Complete below)
OTHER (Identify)
METHOD OF CANCELLATION
FULL TERM
PREMIUM
$
UNEARNED
FACTOR
RETURN
PREMIUM
$
FLAT
SHORT RATE
PRO RATA
PREMIUM CALCULATION
SUBJECT TO AUDIT
COMPANY
POLICY
NUMBER
EFFECTIVE DATE
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
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.
FOR AGENCY / COMPANY USE
ACORD 35 (2010/07) © 1988-2010 ACORD CORPORATION. All rights reserved.
AUTHORIZED SIGNATURE TITLE DATE
(Not applicable in NH per RSA 412:5 I)
LIENHOLDER MORTGAGEE LOSS PAYEE
LIENHOLDER MORTGAGEE LOSS PAYEE
SIGNATURE OF NAMED INSURED DATE
SIGNATURE OF NAMED INSURED DATE
WITNESS DATE
WITNESS DATE
POLICY RELEASE STATEMENT
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 its 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.
CANCELLATION REQUEST (Policy attached) POLICY RELEASE (Complete Statement Section Below)
AUTHORIZED SIGNATURE TITLE DATE
(Not applicable in NH per RSA 412:5 I)
DATE (MM/DD/YYYY)
CANCELLATION REQUEST / POLICY RELEASE
PHONE
(A/C, No, Ext):
PRODUCER
CODE: SUB CODE:
CUSTOMER ID:
AGENCY
POLICY
TYPE
NAIC CODE:
COMPANY NAME AND ADDRESS
INSURED NAME AND ADDRESS
CANCELLATION DATE TIME
AM
PM
EFFECTIVE DATE AND
HOUR OF CANCELLATION
POLICY TERM
EFFECTIVE DATE EXPIRATION DATE
CANCELLED POLICY INFORMATION
POLICY
NUMBER
The ACORD name and logo are registered marks of ACORD
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CANCELLATION REQUEST POLICY RELEASE (Standard Lines Services)

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Completed 1 December 2020

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