Transcription of CANCELLATION REQUEST / POLICY RELEASE DATE …
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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. 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 (2010/07) 1988-2010 ACORD CORPORATION. All rights SIGNATURETITLEDATE(Not applicable in NH per RSA 412:5 I)LIENHOLDERMORTGAGEELOSS PAYEELIENHOLDERMORTGAGEELOSS PAYEESIGNATURE OF NAMED INSUREDDATESIGNATURE OF NAMED INSUREDDATEWITNESSDATEWITNESSDATEPOLICY RELEASE STATEMENTThe 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 occur after the date of CANCELLATION shown premium adj
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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CANCELLATION REQUEST / POLICY RELEASE DATE, POLICY, Date, III, President Effective Date: October 7, PERSONAL POLICY CHANGE REQUEST EXCEPT AUTO, REQUEST FOR TRACING INSURANCE POLICY INFORMATION, MECHANICAL BREAKDOWN ANALYSIS Administrator Policy, MECHANICAL BREAKDOWN ANALYSIS Administrator Policy / Contract, DIRECTIVES TRANSMITTAL