ACORD 35 — Cancellation Request / Policy Release

1 · Producer

Date (MM/DD/YYYY)

Producer (Agency)

Producer Mailing Address

Phone (A/C, No, Ext)

Address Line 2 (optional)

City

State

Zip

Code

Sub Code

Agency Customer ID

2 · Insurance Company

Company Name

NAIC Code

Address

Address Line 2 (optional)

City

State

Zip

3 · Insured & Policy

Policy Type

Insured Name

Insured Address

Address Line 2 (optional)

City

State

Zip

4 · Cancelled Policy Information

Policy Number

Cancellation Date

Cancellation Time

AM / PM

AM PM

Policy Effective Date

Policy Expiration Date

5 · Type of Request

Check ONE. "Policy Release" requires the SIGNATURES section below to be completed.

Cancellation Request (policy attached) Policy Release (signatures required)

6 · Signatures (Policy Release only)

First named insured signs at top. Witnesses + second signer optional. Additional Interest signatures (lienholder / mortgagee / etc.) below — leave blank if none.

Witness 1 + Named Insured 1

Witness (Print)

Date

Named Insured (Signature)

Date

Witness 2 + Named Insured 2 (optional)

Witness (Print)

Date

Named Insured (Signature)

Date

Additional Interest 1 (Lienholder / Mortgagee / Loss Payee / Lender's Loss Payable)

Lienholder Mortgagee Loss Payee Lender's Loss Payable

Name (optional — for your records)

Address Line 1 (optional)

City

State

Zip

Authorized Signature

Title

Date

Additional Interest 2 (optional)

Lienholder Mortgagee Loss Payee Lender's Loss Payable

Name

Address Line 1

City

State

Zip

Authorized Signature

Title

Date

7 · Reason & Method of Cancellation (Agency / Company Use)

Reason for Cancellation

Not Taken Requested by Insured Rewritten Other

Other (Identify)

Company (if Rewritten / Other)

Policy Number (repeated)

Effective Date (repeated)

Method of Cancellation

Flat Short Rate Pro Rata Premium Calculation Subject to Audit

Full Term Premium ($)

Unearned Factor

Return Premium ($)

Remarks (ACORD 101 may be attached if more space is required)

8 · Request / Release Distribution

Name

Address

Address Line 2 (optional)

City

State

Zip

Distributed to

Producer's Signature

Date