CANCELLATION REQUEST / POLICY RELEASE
REASON FOR CANCELLATION
LOSS PAYEE
MORTGAGEE
CANCELLATION REQUEST (Policy attached)
POLICY RELEASE (Complete Statement Section Below)
PHONE
(A/C, No, Ext):
CANCELLED POLICY INFORMATION
POLICY RELEASE STATEMENT
FOR AGENCY/COMPANY USE
METHOD OF CANCELLATION
NAME AND ADDRESS REQUEST/RELEASE DISTRIBUTION
ACORD 35 (1/97)
DATE (MM/DD/YY)
PRODUCER
CODE: SUB CODE:
AGENCY
CUSTOMER ID:
COMPANY NAME AND ADDRESS
NAIC CODE:
POLICY
TYPE
INSURED NAME AND ADDRESS
POLICY
NUMBER
EFFECTIVE DATE AND
HOUR OF CANCELLATION
CANCELLATION DATE
TIME
AM
PM
POLICY TERM
EFFECTIVE DATE
EXPIRATION DATE
WITNESS
DATE
WITNESS
DATE
SIGNATURE OF NAMED INSURED
DATE
SIGNATURE OF NAMED INSURED DATE
AUTHORIZED SIGNATURE
TITLE
DATE
AUTHORIZED SIGNATURE TITLE
DATE
LIEN HOLDER MORTGAGEE LOSS PAYEE
LIEN HOLDER
FULL TERM
PREMIUM
$
UNEARNED
FACTOR
RETURN
PREMIUM
$
PRODUCER'S SIGNATURE
DATE
NOT TAKEN
REQUESTED BY INSURED
REWRITTEN
(Complete below)
OTHER (Identify)
COMPANY
POLICY
NUMBER
EFFECTIVE DATE
REMARKS
FLAT
SHORT RATE
PRO RATA
PREMIUM CALCULATION
SUBJECT TO AUDIT
INSURED
MORTGAGEE
COMPANY
LOSS PAYEE
LIEN HOLDER
FINANCE COMPANY
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.
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.
© ACORD CORPORATION 1988
