Request for cancellation of insurance policy
Your full name
Street address
City State ZIP code
Phone number
I have obtained a policy with another company and am sending you this written notice to request
cancellation of my current insurance policy. My information is listed below.
Policy type: Auto
Home / renters
Policy number
Cancellation date (MM/DD/YY)
Time (HH:MM)
My new insurance company's name
My new policy number
Date this policy is effective (MM/DD/YY)
Time (HH:MM)
Please confirm this cancellation and send the unused portion of my premium to the address
Your signature
Your printed or typed name
Date of signature (MM/DD/YY)