CANCELLATION REQUEST / POLICY RELEASE

INSUREDMORTGAGEECOMPANYLOSS PAYEELIENHOLDERFINANCE COMPANYREQUEST / RELEASE DISTRIBUTIONNAME AND ADDRESSPRODUCER'S SIGNATUREDATEREASON FOR CANCELLATIONNOT TAKENREQUESTED BY INSUREDREWRITTEN(Complete below)OTHER (Identify)METHOD OF CANCELLATIONFULL TERMPREMIUM$UNEARNEDFACTORRETURNPREMIUM$ FLATSHORT RATEPRO RATAPREMIUM CALCULATIONSUBJECT TO AUDITCOMPANYPOLICY NUMBEREFFECTIVE DATEREMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)New York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will besuspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To avoid these penalties, you mustsurrender your registration certificate and plates before your insurance expires. By law, we must report the termination of auto insurancecoverage to the Department of Motor AGENCY / COMPANY USEACORD 35 (2011/09) 1988-2011 ACORD CORPORATION.

insured mortgagee company loss payee lienholder finance company name and address request / release distribution producer's signature date reason for cancellation

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