Insurance Policy Cancellation Form

Insurance Policy Cancellation Form

Applicant / Insured Information

Date of birth:    Phone:    Email:

Policy Details

Insurance company:

Policy number:    Policy type:

Coverage limit:    Deductible:    Premium (annual):

Policy period from:    to:

Cancellation Request

I hereby request cancellation of the policy identified above as follows:

Cancel entire policy    Cancel selected coverages only    Non-renewal at term expiration

Liability    Collision    Comprehensive    Personal Injury Protection

Uninsured/Underinsured Motorist    Property    Life/AD&D Benefit

Voluntary cancellation    Premium non-payment    Replacement policy obtained    Fraudulent activity suspected

Other (describe):

Requested effective cancellation date:    If different, actual cancellation date to be processed by insurer:

Refund, Premium and Financial Instructions

I request that any refund or unearned premium be processed as follows (select one):

Issue check to mailing address on file    Apply credit to outstanding balance    ACH deposit to bank account below

Premium paid through date:    Estimated prorated refund (if known):

Beneficiary Information (if policy has beneficiary)

Supporting Documentation Checklist

Please attach or provide copies of any documents necessary to process this cancellation. Check all provided:

Returned original policy documents    Replacement policy declaration    Signed release or written consent from lienholder

Exclusions and Important Notices

The insurer may deny or delay a cancellation request if there are outstanding premiums, unresolved claims, or suspected fraud. Cancellation does not extinguish liabilities for losses occurring prior to the effective cancellation date. Any refund will be calculated in accordance with the policy terms and the insurer's customary premium accounting procedures. The applicant remains responsible for premiums due for all coverage periods prior to the effective cancellation date.

If a lienholder or mortgagee is recorded on the policy, the insurer will provide notice of cancellation to the lienholder as required by the policy or applicable law. The applicant warrants that all information provided on this form is true and complete to the best of their knowledge.

Declaration and Authorization

I, the undersigned, hereby request cancellation of the insurance policy identified above. I certify that I am authorized to request cancellation for the named insured and that the information provided in this request is true and correct. I understand that processing this cancellation may result in a short-rate or pro-rata premium adjustment as provided in the policy. I authorize the insurer to release or obtain information necessary to process this request and any refund due.

I acknowledge that cancellation will be effective only when accepted by the insurer and that the insurer may require additional documentation. I understand that any refund will be payable to the insured or lienholder as required by the policy or law.

Signature

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