Acord Cancellation Form
Date
-
Month
-
Day
Year
Date
Producer
Agency that is on the policy that is being cancelled
Company Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency ID
Code
Insurer
The actual company name within the group to which the policy has been issued.
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NAIC Code
(National Association of Insurance Commissioner)
Policy Information
Policy Type
Personal Auto
Truckers
Garage Liability
Commercial Property
Builder's risk
Other
Policy Number
Effective Date of the Cancellation
-
Month
-
Day
Year
Date
Effect Time of the Cancellation
Hour Minutes
AM
PM
AM/PM Option
Policy Term Effective Date
-
Month
-
Day
Year
Date
Policy Term Expiration Date
-
Month
-
Day
Year
Date
Insured Name
First Name
Last Name
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Policy Release
Reason for Cancellation
Not Taken
Requested by Insurred
Rewritten
Other
Method of cancellation
Short Rate
Pro Rata
Flat
If you need to notify a 3rd party, please fill up the fields below:
Request/Release Distribution
Insured
Mortgage
Company
Loss Payee
Lienholder
Finance Company
Lender's Loss Payable
Name
First Name
Last Name
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signatures
Witness Name / Insured Member Name
First Name
Last Name
Witness Signature
Date Signed
-
Month
-
Day
Year
Date
Producer's Signature
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
Should be Empty: