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this form is used as tangible evidence of the insured’s instruction to cancel a contract. * method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. company name and address issuing company’s name, naic code, and address shown on the policy being cancelled or released. insured name and address name, mailing address and zip code of the insured as it appears on the policy. effective date and hour of cancellation list the effective date of the policy cancellation in month/day/year format.
witness when this document is used as a policy release, an insured should have a witness sign and date the form before returning it to the agent. the signature and title of an authorized representative of any additional interest indicated in the contract must be obtained if the document is used as a policy release. method of cancellation mark “x” in the appropriate box indicating method of cancellation. unearned factor unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to date of policy expiration. the line within the name and address field is a margin setting used for window envelopes.
by law, we must report the termination of auto insurance coverage to the department of motor vehicles. remarks ( by law, we must report the termination of auto insurance coverage to the department of motor vehicles. © acord acord 35 (1/97) – cancellation request/policy release it explains information the company needs to process the transaction. this form is used as tangible evidence of the insured’s instruction to cancel a contract., acord 35 2017 fillable, acord 35 2017 fillable, cancellation request form template, acord auto policy cancellation form, acord blank cancellation form.
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