Insurance Cancellation HO4 Form

INSURANCE CANCELLATION — HO‑4 (RENTERS) POLICY

Insured Name:    Policy Number:

Insurer Name:    Agent/Broker:

Insured and Property Information

Date of Birth (Insured):

Policy Period

Policy Period From:    To:

Cancellation Details

I hereby request cancellation of the above HO‑4 policy. Indicate the primary nature of this cancellation (check all that apply):

Requested by insured    Initiated by company    Non‑renewal

Requested Cancellation Effective Date:

Reason for Cancellation

Non‑payment of premium    Moving / no longer occupying residence    Policy replaced by other insurer

Fraud or material misrepresentation alleged    Voluntary cancellation for other reason    Other

Coverage Affected

Check coverages to be cancelled or adjusted:

Personal Property (Coverage C)    Personal Liability    Additional Living Expenses / Loss of Use

Medical Payments to Others    Other (describe below)

Exclusions and Outstanding Matters

The following exclusions, pending claims, or conditions may affect cancellation and refund calculations. Indicate any that apply:

Open claims or reported losses    Suspected fraud or misrepresentation    Inspection or loss control required

Return Premium / Refund Instructions

Refund Payable To:

Refund Method (check one or more as appropriate):

Mail check to mailing address listed above    Apply credit to new policy with this insurer    Electronic funds transfer (EFT) — provide account details below

Certification and Authorization

By signing below, the undersigned certifies that the information provided in this cancellation request is true, complete, and submitted in good faith. The undersigned understands and agrees that:

1. Cancellation will be effective on the date accepted by the insurer or as otherwise required by the policy terms and applicable law. Any premium refund will be subject to the insurer's earned premium calculation, adjustment for fees or short‑rate penalties where permitted, and any offsets for outstanding claims.

2. The insurer reserves the right to investigate and to deny or delay cancellation where there are pending or suspected claims, misrepresentations, or material nondisclosures by the insured.

3. The insured authorizes release of information necessary to process this cancellation request and any refund, and agrees to indemnify the insurer for damages arising from false or misleading statements.

4. The insured acknowledges receipt of any required notice of cancellation and understands any local or statutory notice periods that may apply.

I certify under penalty of perjury that I am authorized to request cancellation of the policy identified herein and that the statements made on this form are true and correct to the best of my knowledge.

Sign Now