Transcription of POLICY CANCELLATION REQUEST / POLICY …
1 The undersigned agrees that: Requested CANCELLATION dates will be made effective the date received by the general agent, unless a future CANCELLATION date is requested. Requested CANCELLATION dates prior to today s date, due to the purchase of another POLICY , must include proof of duplicate coverage in the form of a declarations page. Policies not accepted by the insured due to an uprate, and returned to the general agent postmarked within 15 days of the date of issuance will be cancelled pro-rata. The above-referenced POLICY is lost, destroyed, or is being retained. No 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 above. Any premium adjustment will be made in accordance with the terms and conditions of the POLICY . Reason for CANCELLATION : Not taken due to uprate Duplicate coverage / re-written Effective date of new POLICY : _____ Insured s REQUEST X_____ _____ Signature of Named Insured Date X_____ _____ Signature of Producer Date WGIS TX CANCELLATION REQUEST (04 09) WESTERN GENERAL INSURANCE SERVICES 5230 Las Virgenes Road, Calabasas, CA 91302 POLICY NUMBER: REQUESTED CANCELLATION DATE: Cannot be prior to today s date without proof of duplicate coverage accepted by the General Agent.
2 PRODUCER NAME and ADDRESS: PRODUCER CODE NUMBER: INSURED NAME and ADDRESS: POLICY CANCELLATION REQUEST / POLICY RELEASE FORM
