Fillable First Name Last name or Cancellation Department Name

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First Name Last name or Cancellation Department Name

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Date
First Name Last name or Cancellation Department
Name of Insurance Company
Company's Mailing Address or PO Box
Company's City, State, Zip Code
Re: Policy Number: #______________________Cancellation
I am sending you this written notice to request cancellation of my insurance policy effective [insert
cancellation date]. I would appreciate you sending me written confirmation within 30 days that the
cancellation has been put into effect. Please refund the unused portion of my policy premium, and
cease charging my bank account for payment of monthly premiums.
Thank you for your prompt attention to this matter.
Sincerely,
[Your Signature]
Your First Name Last name
Your Mailing Address or PO Box
Your City, State, Zip Code
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First Name Last name or Cancellation Department Name

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Completed 21 December 2020

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