Insurance Refund Request Letter

Insurance Refund Request Letter

Insurer / Recipient

Date:    Policy Number:    Insured ID:

Applicant / Insured Information

Policy Details

Policy Type: Auto Homeowners Renters Life Health Commercial Other:

Policy Period: From to    Official Cancellation Date (if applicable):

Reason for Refund Requested

Please select the reason(s) for this refund request (select all that apply):

Policy cancelled by policyholder
Overpayment or duplicate premium
Credit due after endorsement or adjustment
Return of security or premium deposit
Other (explain below)

Requested Refund Amount and Calculation

Amount Requested: $

Applicant asserts the following components support the refund calculation:

Documentation Checklist

Include copies of the following documents as applicable. Check each box and attach supporting documentation to this request.

Policy declaration page
Proof of payment (receipt, bank statement)
Cancellation notice or endorsement
Evidence of duplicate payment
Other supporting documents (describe below)

Payee / Refund Disbursement Instructions

Preferred method of disbursement: Check mailed Electronic deposit (ACH) Apply as credit to another policy

Exclusions, Offsets and Adjustments

The insurer may reduce or deny refund amounts for the following reasons: non-refundable policy fees, earned premium calculated pro rata or by short-rate when permitted by policy terms, taxes, assessments or statutory charges, amounts due on any outstanding balances, and amounts associated with paid claims or reserves. This request does not waive the insurer's right to audit payments, apply offsets, or to apply policy terms that govern refund computations.

Declaration and Authorization

I certify under penalty of perjury that the information provided in this Insurance Refund Request Letter and all attachments are true, complete and accurate to the best of my knowledge. I authorize the insurer to verify payment records, to compute or adjust any earned premium in accordance with the policy terms, and to make any lawful offsets against amounts otherwise payable. I further authorize issuance of the refund to the payee and by the disbursement method specified above. I acknowledge that processing may take time and that the insurer may deduct lawful fees, taxes, or earned premium prior to disbursement. I agree to promptly notify the insurer of any changes to payee or banking information and hold the insurer harmless for deposits made in good faith to the account or payee provided herein.

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