Cancel Policy Request Form

Named Insured(Required)

This should be the policyholder on the account

First Last

Policyholder Email(Required)

This should match the email address we have on file and where confirmation of the policy cancellation will be sent.

Address(Required)

If address has changed from what we currently have on file, please make sure to advise our office, PRIOR to moving forward with this cancel request.

Street Address City State ZIP Code

Reason for Policy Cancellation(Required)

Price

Vehicle/Property Sold

Relocating out of service area

Agency Service

Carrier Service / Claims Issue

Other

Please elaborate

We're always look for way to improve our carrier selection to remain competitive in the marketplace and to provide an excellent customer experience. We welcome your honest feedback.

Would you want a second look at your new policy?

Would you be interested in allowing us to review your new policy coverage, limits and exclusions to ensure that you're getting matching or better coverages for the lower price you found?

Yes - I would love that!

No - I'm confident I made the right choice for me and & my family.

Insurance Company(Required)

This should be the name of the insurance company you're looking to cancel.

Policy Type(Required)

General Liability

Commercial Property

Professional Liability

Umbrella

Commercial Auto

Policy Number(Required)

This should be the policy number you're looking to cancel.

Cancellation Effective Date(Required)

This is the date that you would like to have the policy referred above cancelled. PLEASE NOTE: Backdating a cancel request, will NOT be processed without proof that replacement coverage was in effect on the date of the request. If today's date is selected, any and coverage on the policy will be cancelled immediately upon processing. If a future day is selected, coverage will terminate at 12:01am on the date selected.

Policy Effective Date(Required)

Please enter the date of your CURRENT policy's current effective date.

Policy Expiration Date(Required)

Please enter the date of your CURRENT policy's current expiration date.

Upload File

If you requesting that we cancel a policy with a retroactive date, please provide proof that your new coverage was in effect on date of the requested cancellation. ONLY PROOF ACCEPTABLE: New policy declarations page or Binder. ID Cards or screen shots WILL NOT be accepted.

Accepted file types: pdf, Max. file size: 5 MB.

Please read the following in order to complete your request(Required)

I understand and agree to the following:

I am the policyholder shown above and am authorizing that the above referenced policy(ies) be cancelled per my request

My cancel request has NOT been processed and that this form is only the first step to cancelling my policy

Until confirmation of the cancelled request is received by me, coverage has NOT been cancelled

I will receive a document via email that REQUIRES my e-signature and that my request cannot be processed without completion of this form

Any scheduled payments will be processed according to the terms of my policy until my completed request has been processed and cancellation confirmation is received

If I fail to upload any required documents to backdate my cancel request, my request WILL NOT be processed

My Insurance Group, its agents, affiliates and carrier partners cannot be held liable for incomplete requests.

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Cancel Request