ACORD Policy Cancellation Form

A standardized ACORD-style form insurance agencies use to process and document the formal cancellation of a policyholder's coverage.

Use this template

Date

Agency name

Email

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Agency ID

Code

Insurance company name

Insurer address

Dirección

Ciudad

Estado / Provincia

Código postal

NAIC code

Policy number

Cancellation effective date

Cancellation effective time

Policy term effective date

Policy term expiration date

Insured's name

Nombre

Apellido

Insured's company name

Insured's address

Dirección

Ciudad

Estado / Provincia

Código postal

Insured's phone number

Insured's email

Reason for cancellation

Non-payment Insured's request Underwriting decision Other

Method of cancellation

Flat cancellation Pro rata Short rate

Text

Request/release distribution

Insured Lienholder Other

Name

Nombre

Apellido

Company name

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Witness / insured member name

Nombre

Apellido

Witness signature

Sign here

Date signed

Producer's signature

Sign here

Date signed

ACORD Policy Cancellation Form

Related templates