Cancellation/Lost Policy Release Form

What is the name of the insurance company that provides the policy being cancelled?*

What is the name of the insurance company that provides the policy being cancelled?

What is the address of the insurance company?*

What is the address of the insurance company?

Street Address Address Line 2 City State ZIP Code

What is the NAIC code for the insurance company that provides the policy being cancelled?

What date is this form being completed?*

What date is this form being completed?

What type of policy is being cancelled?*

What type of policy is being cancelled?

What is the policy number of the policy being cancelled?*

What is the policy number of the policy being cancelled?

What date would you like this policy to be cancelled?*

What date would you like this policy to be cancelled?

What time would you like this policy to be cancelled?

:

What is the effective date of this policy?*

What is the effective date of this policy?

What is the expiration date of this policy?*

What is the expiration date of this policy?

What is the name of the producing agency for this policy?*

What is the name of the producing agency for this policy?

What is the address of the producing agency for this policy?*

What is the address of the producing agency for this policy?

Street Address Address Line 2 City State ZIP Code

What is the phone number of the producing agency?*

What is the phone number of the producing agency?

What is the agency code?

What is the agency subcode?

What is the agency customer ID?

What is the name of the insured requesting this cancellation?*

What is the name of the insured requesting this cancellation?

What is the address of the insured requesting this cancellation?*

What is the address of the insured requesting this cancellation?

Street Address Address Line 2 City State ZIP Code

What type of cancellation is this?

Cancellation Request (Policy attached)
Policy Release (Complete Statement Section Below)

Policy Release Statement - The undersigned agrees that: The above referenced policy is lost, destroyed or 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.

Enter the first named insured’s signature in the box below.

Enter the date of the first named insured’s signature.

Enter the second named insured’s signature in the box below.

Enter the date of the second named insured’s signature.

Enter the first witness’s signature in the box below.

Enter the date of the first witness’s signature.

Enter the second witness’s signature in the box below.

Enter the date of the second witness’s signature.

Are any authorized signature’s required for this cancellation?

Yes
No

Authorized Signatures

Enter the name of the first authorized person/entity.

What is the first type of authorized signature?

Lienholder
Mortgagee
Loss Payee

Enter the first authorized signature in the box below.

What is the first authorized person’s title?

Enter the date of the first authorized person’s signature.

Enter the name of the second authorized person/entity.

What is the second type of authorized signature?

Lienholder
Mortgagee
Loss Payee

Enter the second authorized signature in the box below.

What is the second authorized person’s title?

Enter the date of the second authorized person’s signature.

This field is hidden when viewing the form

End Authorized Signatures

For Agency/Company Use

What is the reason for cancellation of this policy?*

What is the reason for cancellation of this policy?

Not Taken
Requested by Insured
Rewritten
Other

Please explain the reason this policy is being cancelled.

What is the name of the insurance company this policy was rewritten to?

What is the new policy number?

What is the effective date of the new policy?

Method Of Cancellation

What is the method of cancellation for this policy?

Flat
Short Rate
Pro Rata

Will any return premium calculation be subject to an audit?

Yes
No

What was the full term premium of the policy being cancelled?

What is the unearned factor for this cancellation?

What is the return premium for this cancellation?

Enter any additional remarks in the space below.

New York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will be suspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To 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 Vehicles.

Request/Release Distribution

Click here if the name and address of the insured and the entity/individual who will receive any distribution are the same.

Click here if the name and address of the insured and the entity/individual who will receive any distribution are the same.

What is the name of the entity/individual whom will receive any distribution?*

What is the name of the entity/individual whom will receive any distribution?

What is the address of the entity/individual whom will receive any distribution?

Street Address Address Line 2 City State ZIP Code

Select the option below for the person/entity whom will receive any distribution.

Enter the producer’s signature in the box below.

Enter the date of the producer’s signature.

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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be cancelled or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *

I agree*

Cancellation/Lost Policy Release Form

Authorized Signatures

End Authorized Signatures

For Agency/Company Use

Method Of Cancellation

Request/Release Distribution

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Cancellation/Lost Policy Release Form

Authorized Signatures

End Authorized Signatures

For Agency/Company Use

Method Of Cancellation

Request/Release Distribution

Ted Mara

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter