CANCELLATION REQUEST / POLICY RELEASE

The ACORD name and logo are registered marks of ACORDPOLICY NUMBERCANCELLED POLICY INFORMATIONEXPIRATION DATEEFFECTIVE DATEPOLICY TERMEFFECTIVE DATE ANDHOUR OF CANCELLATIONPMAMTIMECANCELLATION DATEINSURED NAME AND ADDRESSNAIC CODE: POLICY TYPECOMPANY NAME AND ADDRESSAGENCYCUSTOMER ID:SUB CODE:CODE:(A/C, No, Ext):PHONEPRODUCERCANCELLATION REQUEST / POLICY RELEASEDATE (MM/DD/YYYY)This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act.(Not applicable in NH per RSA 412:5 I)DATETITLEAUTHORIZED SIGNATUREPOLICY RELEASE (Complete SIGNATURES section below) CANCELLATION REQUEST ( POLICY attached)Any premium adjustment will be made in accordance with the terms and conditions of the this POLICY for losses which occur aft

policy number cancelled policy information effective date expiration date policy term effective date and hour of cancellation pm cancellation date time am insured name and address naic code: policy type company name and address agency customer id: code: sub code: (a/c, no, ext): producer phone cancellation request / policy release date (mm/dd/yyyy)

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  Policy, Release, Request, Cancellation, Cancellation request, Policy release

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