Transcription of CANCELLATION REQUEST / POLICY RELEASE DATE …
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Example: marketing
CANCELLATION REQUEST / POLICY RELEASE DATE …
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 AUDITCOMPANYPOLICYNUMBEREFFECTIVE DATEREMARKS (Attach ACORD 101, Additional Remarks Schedule, 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.
insured mortgagee company loss payee lienholder finance company name and address request / release distribution producer's signature date reason for cancellation not taken requested by insured
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