Transcription of CANCELLATION REQUEST / POLICY RELEASE DATE …
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CANCELLATION REQUEST / POLICY RELEASE DATE …
CANCELLATION REQUEST / POLICY RELEASECANCELLED POLICY INFORMATIONCANCELLATION REQUEST ( POLICY attached) POLICY RELEASE (Complete Statement Section Below) POLICY RELEASE STATEMENTFOR AGENCY/COMPANY USEREASON FOR CANCELLATIONMETHOD OF CANCELLATIONNAME AND ADDRESSREQUEST/ RELEASE DISTRIBUTIONACORD 35 (1/97)cOACORD CORPORATION 1988 date (MM/DD/YY)PRODUCERPHONE(A/C, No, Ext):CODE:SUB CODE:AGENCYCUSTOMER ID:COMPANY NAME AND ADDRESSNAIC CODE:POLICYTYPEINSURED NAME AND ADDRESSPOLICYNUMBEREFFECTIVE date ANDHOUR OF CANCELLATIONCANCELLATION DATETIMEAMPMPOLICY TERMEFFECTIVE DATEEXPIRATION DATEWITNESSDATEWITNESSDATESIGNATURE OF NAMED INSUREDDATESIGNATURE OF NAMED INSUREDDATEAUTHORIZED SIGNATURETITLEDATEAUTHORIZED SIGNATURETITLEDATELIEN HOLDERMORTGAGEELOSS PAYEELIEN HOLDERMORTGAGEELOSS PAYEEFULL TERMPREMIUM$UNEARNEDFACTORRETURNPREMIUM$ PRODUCER S SIGNATUREDATENOT TAKENREQUESTED BY INSUREDREWRITTEN(Complete below)OTHER (Identify)COMPANYPOLICYNUMBEREFFECTIVE DATEREMARKSFLATSHORT RATEPRO RATAPREMIUM CALCULATIONSUBJECT TO AUDITINSUREDMORTGAGEECOMPANYLOSS PAYEELIEN HOLDERFINANCE COMPANYThe undersigned agrees that:The above referenced POLICY is lost, destroyed or being claims of any type will be made against the Insurance Company, its agents or its representatives,under this POLICY for losses which oc
CANCELLATION REQUEST / POLICY RELEASE CANCELLED POLICY INFORMATION CANCELLATION REQUEST (Policy attached) POLICY RELEASE (Complete Statement Section Below)
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