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CANCELLATION REQUEST / POLICY RELEASE DATE …

CANCELLATION REQUEST / POLICY RELEASEREASON FOR CANCELLATIONLOSS PAYEEMORTGAGEECANCELLATION REQUEST ( POLICY attached) POLICY RELEASE (Complete Statement section Below)PHONE(A/C, No, Ext):CANCELLED POLICY INFORMATIONPOLICY RELEASE STATEMENTFOR AGENCY/COMPANY USEMETHOD OF CANCELLATIONNAME AND ADDRESSREQUEST/ RELEASE DISTRIBUTIONACORD 35 (1/97)DATE (MM/DD/YY)PRODUCERCODE: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 HOLDERFULL TERMPREMIUM$UNEARNEDFACTORRETURNPREMIUM$ PRODUCER'S SIGNATUREDATENOT TAKENREQUESTED BY INSU

cancellation request (policy attached) policy release (complete statement section below) phone (a/c, no, ext): cancelled policy information policy release statement for agency/company use method of cancellation name and address request/release distribution acord 35 (1/97) date (mm/dd/yy) producer code: sub code: agency customer id: company name ...

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LS-71 Ed. 9/02 LS-71 Ed. 9/02 ADDITIONAL INSURED-VENDORS BROAD FORM Applies to Commercial General Liability Coverage Refer to Supplemental Declarations if information is not shown on this form.

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COMMERCIAL GENERAL LIABILITY SECTION DATE …

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