Transcription of CANCELLATION REQUEST / POLICY RELEASE
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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 after the date of CANCELLATION shown claims of any type will be made against the Insurance Company, its agents or its representatives,The above referenced POLICY is lost, destroyed or being undersigned agrees th
CANCELLATION REQUEST POLICY RELEASE (Complete SIGNATURES section below) (Policy attached) Any premium adjustment will be made in accordance with the terms and conditions of the policy. under this policy for losses which occur after the date of cancellation shown above.
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