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. If your vehicle is still uninsured after 90 days, your driver's license will be suspended.
cancellation request / policy release date (mm/dd/yyyy) phone (a/c, no, ext): producer code: sub code: customer id: agency policy type company name and address naic code: insured name and address cancellation date time am pm effective date and hour of cancellation policy …
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