CANCELLATION REQUEST / POLICY RELEASE DATE …

1 CANCELLATION REQUEST / POLICY RELEASECANCELLED POLICY INFORMATIONCANCELLATION REQUEST ( POLICY attached) POLICY RELEASE (Complete Statement Section Below) POLICY RELEASE STATEMENTFOR AGENCY/COMPANY USEREASON FOR CANCELLATIONMETHOD OF CANCELLATIONNAME AND ADDRESSREQUEST/ RELEASE DISTRIBUTIONACORD 35 (1/97)cOACORD CORPORATION 1988 date (MM/DD/YY)PRODUCERPHONE(A/C, No, Ext):CODE: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 HOLDERMORTGAGEELOSS PAYEEFULL 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 vehicleregistration will be suspended. If your vehicle is still uninsured after 90 days, your driver s license will be avoid these penalties, you must surrender your registration certificate and plates before your insurance expires. By law,we must report the termination of auto insurance coverage to the Department of Motor