In order to process your cancellation request please complete the form in its entirety. We will process your request once the form is signed, dated, completed, and received by our office. All fields below must be filled out with the accurate information needed.  

Insured Name:  

Policy Number:  

Insurance Carrier:  

Policy Type:

Effective Date of Cancellation at 12:01 AM Local Time at Residence Premises:

Cancellation Reason:  

The undersigned agrees that:
The above referenced policy is lost, destroyed or being retained. No claims of any type will be made against the Insurance Company, its agents or its representatives, under this policy for losses which occur after the date of cancellation show above. Any premium adjustment will be made in accordance with the terms and conditions of the policy.

Date Signed:

No request for cancellation date prior to your completion of this Lost Policy Release shall be honored. Cancellations may only be effective as of the date and time this document is received by the insurance carrier ortheir Agent. Please be advised that all premium due for coverage up to the date and time this document is received shall remain earned, due, and payable.

New York Auto Insurance & Where Applicable: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will be suspended. If your vehicle is still uninsured after 90 days, your driver’s license will be suspended. To avoid these penalties, you must surrender your registration certificate and plates before your insurance expires. By law, we must report the termination of auto insurance coverage to the Department of Motor Vehicles.

Your legal name

Your Email Address


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Signature Certificate
Document name: Policy Cancellation Request
lock iconUnique Document ID: 0ae5b7e41a6c7a8ddaada509a2b4a75576e7e7d1
Timestamp Audit
May 24, 2024 2:15 pm EDTPolicy Cancellation Request Uploaded by Burt Conklin - IP
May 24, 2024 2:15 pm EDTEC Team - added by Burt Conklin - as a CC'd Recipient Ip:
June 10, 2024 4:14 pm EDTEC Team - added by Burt Conklin - as a CC'd Recipient Ip: