Fillable TX Policy Cancellation CLEAR SPRING PROPERTY AND CASUALTY

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TX Policy Cancellation CLEAR SPRING PROPERTY AND CASUALTY

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Policy Cancellation
4. Effective Date
1. Insured Name
3. Policy Type
InsuredCancellationStateTXCompany178Rev20200406.xpd | © PC Processing
Policy NumberState
Page 1-1
5. Cancellation Date
TX
2. Address
6. Time of Cancellation
POLICY RELEASE STATEMENT
The undersigned agrees that:
The above reference 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 and hour of cancellation shown above. Any premium adjustment
will be made in accordance with the terms and conditions of the policy.
8a. Witness Signature 8b. Date
7b. Date7a. Insured Signature
9. Reason for Cancellation
____ Request by Agent ____ Request by Insured ____ Rewritten ____ Other (Specify)
10. Additional Comments
Please Fax To 1 713-490-3214
CLEAR SPRING PROPERTY AND CASUALTY COMPANY
Administered By Jubilee General Agency | 707-777-2626
888 W Sam Houston Pkwy S, Ste 188, Houston, TX 77042
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TX Policy Cancellation CLEAR SPRING PROPERTY AND CASUALTY

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Completed 19 January 2021

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