Transcription of CANCELLATION REQUEST / POLICY RELEASE
1 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 AUDITCOMPANYPOLICY NUMBEREFFECTIVE DATEREMARKS (ACORD 101, Additional Remarks Schedule, may be attached 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.
2 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 (2011/09) 1988-2011 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 adjustment will be made in accordance with the terms and conditions of the REQUEST ( POLICY attached) POLICY RELEASE (Complete Statement Section Below)AUTHORIZED SIGNATURETITLEDATE(Not applicable in NH per RSA 412.)
3 5 I)This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent (MM/DD/YYYY) CANCELLATION REQUEST / POLICY RELEASEPRODUCERPHONE(A/C, No, Ext):CODE:SUB CODE:CUSTOMER ID:AGENCYCOMPANY NAME AND ADDRESSPOLICY TYPENAIC CODE:INSURED NAME AND ADDRESSCANCELLATION DATETIMEAMPMEFFECTIVE date ANDHOUR OF CANCELLATIONPOLICY TERMEFFECTIVE DATEEXPIRATION DATECANCELLED POLICY INFORMATIONPOLICY NUMBERThe ACORD name and logo are registered marks of ACORD
