CANCELLATION REQUEST / POLICY RELEASE
CANCELLED POLICY INFORMATION
CANCELLATION REQUEST (Policy attached) POLICY RELEASE (Complete Statement Section Below)
POLICY RELEASE STATEMENT
FOR AGENCY/COMPANY USE
REASON FOR CANCELLATION METHOD OF CANCELLATION
NAME AND ADDRESS REQUEST/RELEASE DISTRIBUTION
ACORD 35 (1/97)
c
O ACORD CORPORATION 1988
DATE (MM/DD/YY)
PRODUCER
PHONE
(A/C, No, Ext):
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 MORTGAGEE LOSS PAYEE
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
TM
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