Policy Cancel Test

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

Leave this empty:

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Signature Certificate
Document name: Policy Cancel Test
lock iconUnique Document ID: 0c0ecb236b39e76d40b19d09ed7715d045f37391
Timestamp Audit
June 10, 2024 4:12 pm EDTPolicy Cancel Test Uploaded by Burt Conklin - burt.conklin@msimga.com IP