Insurance Rescinding Letter

INSURANCE RESCINDING LETTER

Date of Notice:

To: Insurer Name:

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type:    Coverage Amount:    Deductible:

Premium:    Policy Period From:   To:

Grounds for Rescission (select all that apply)

Material misrepresentation in application or supporting documents

Failure to disclose material facts or prior losses

Fraudulent statements or forged documents

Administrative error by insurer (rescission by mutual agreement requested)

Other (explain below)

Statement of Facts

Date policy was issued:    Date of discovery of untrue statement or omission:

Relief Requested

Full return of premium paid

Prorated return of premium from effective rescission date

Offset any amounts paid for claims against refunds as permitted by law

Return of physical policy documents and endorsements

Beneficiary Information (if applicable)

Relationship:    Percentage:

Documentation Checklist

Copy of policy and endorsements

Copy of original application and declarations

Relevant correspondence or underwriting notes

Proof of premium payments

Certifications and Legal Notice

I hereby give notice of rescission with respect to the policy identified above. I understand and acknowledge that, if rescission is permitted under the policy terms and applicable law, rescission shall operate to void the policy ab initio as of the effective date specified by the insurer or otherwise determined by law. I request the insurer take the actions checked in the Relief Requested section above.

I certify under penalty of perjury that the information provided in this Notice is true, complete and correct to the best of my knowledge. I understand that material misrepresentation or omission in this Notice or in supporting documents may result in civil or criminal penalties where applicable. I agree to cooperate with any verification or investigation the insurer deems necessary to process this rescission.

By signing below I request prompt processing of this rescission, including return of premiums as appropriate, and acknowledge that the insurer may offset any sums previously paid for claims to the extent permitted by law. I further acknowledge that receipt of this Notice does not itself constitute acceptance of rescission by the insurer; acceptance, denial, or modification of rescission will be communicated by separate written notice from the insurer.

Acknowledgment

I acknowledge that I have read and understand the consequences of rescission, including potential retroactive voiding of coverage and exposure to liability for amounts paid or owed.

Applicant initials:

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