ACORD 35 (1/97) – Cancellation Request/Policy Release
This guide provides basic instructions for completing the ACORD Cancellation Request/Policy Release form. It explains information the company needs to process the transaction.
This form is used as tangible evidence of the insured’s instruction to cancel a contract. It can be used for either Personal or Commercial Lines, or as an enclosure to the returned original contract, when available.
* Method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. Caution should be exercised to ensure proper signature specifications are followed, as required by the company.
Insured entities must have an authorized signature and title where applicable. Individual companies may have specific requirements for additional information particularly in situations of “Policy Rewritten” or “Pro Rata” cancellations.
Verify that cancellation notice rights have not been extended to additional parties.
Premium financed policies should be discreetly handled to ensure proper transmittal of premium and information.
Month/day/year on which the form was completed.
Name and address of the producer of record whose policy is being cancelled or released.
Phone (A/C, No, Ext)
Producer’s telephone number.
Identifying code assigned to your agency or brokerage firm by the insurance company receiving this form.
If your agency uses a subcode identification system with the company, enter the appropriate code.
Agency Customer ID
Customer’s identification number assigned by the agency.
Company Name and Address
Issuing company’s name, NAIC code, and address shown on the policy being cancelled or released. Do not use group or trade name.
Specific type of insurance (e.g., Automobile Policy, Workers Compensation, Homeowners, etc.).
Insured Name and Address
Name, mailing address and ZIP code of the insured as it appears on the policy. If the policy is issued to multiple named insureds, and the space is not adequate to list them all, enter only the first named insured followed by “et al.”
CANCELED POLICY INFORMATION
Policy Number exactly as it appears on the policy, including both prefix and suffix symbols.
Effective Date and Hour of Cancellation
List the effective date of the policy cancellation in month/day/year format. Enter the time including, AM or PM, that the policy cancellation takes effect.
List the full term effective and expiration dates as listed on the policy.
CANCELLATION REQUEST (Policy Attached)
If this form is being used to notify the carrier of policy cancellation and the insured’s original copy of the policy is attached, check this box and return both this form and original policy to the company.
POLICY RELEASE (Complete Statement Section below)
Mark “X” in this block only if this document is used as a Policy Release (policy not attached).
When this document is used as a Policy Release, an insured should have a witness sign and date the form before returning it to the agent.
Signature of Named Insured
First named insured must sign and date this form when used as either a Cancellation Request or Policy Release.
Provide the name and address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking “X” in the appropriate box.
The signature and title of an authorized representative of any additional interest indicated in the contract must be obtained if the document is used as a Policy Release. Space is provided for the corresponding signature date.
FOR AGENCY/COMPANY USE
Reason for Cancellation
Mark “X” in the appropriate block to indicate the reason for cancellation of the policy. Available options are:
Request of Insured
Rewritten (complete below)
If Rewritten is indicated, enter the new Company, Policy Number, and Inception Date in the spaces provided. If Other is indicated, identify the reason in the space provided.
The name of the company that the rewritten policy has been placed with.
The new policy number for the rewritten policy.
The effective date of the rewritten policy.
Method of Cancellation
Mark “X” in the appropriate box indicating method of cancellation. Available options are:
Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured.
Full Term Premium
Premium for the full term (six months, annual, etc.) of the policy, including endorsements.
Unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to date of policy expiration.
Gross return premium equals the unearned factor multiplied by the full term premium.
List any additional comments regarding the cancellation. Explanations should be made regarding back-dated cancellations or why premium is listed as being pro-rated instead of short-rated.
NAME AND ADDRESS – Request/ Release Distribution
Use these sections to list any additional distributions for this form, including the new agent of record, if any. Check the appropriate box for the corresponding address. The line within the name and address field is a margin setting used for window envelopes.
This form should be signed by the agent completing it.