CANCELLATION REQUEST / POLICY RELEASE DATE …

1 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 INSUREDREWRITTEN(Complete below)OTHER (Identify)COMPANYPOLICYNUMBEREFFECTIVE DATEREMARKSFLATSHORT RATEPRO RATAPREMIUM CALCULATIONSUBJECT TO AUDITINSUREDMORTGAGEECOMPANYLOSS PAYEELIEN HOLDERFINANCE COMPANYThe undersigned agrees that.

2 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 York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration willbe suspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To avoid these penalties, youmust surrender your registration certificate and plates before your insurance expires. By law, we must report the termination of autoinsurance coverage to the Department of Motor Vehicles. ACORD CORPORATION 1988