| Section Name | Field Name | Field and/or Section Description |
| Use ACORD 58, Notice of Cancellation or Termination of a Policy, whenever it is necessary to notify a state motor vehicle bureau that an insurance policyis being cancelled or terminated, and no specific notice form is required. | ||
| TITLE ACORD 58 (2007/11) | Notice of Cancellation or Termination of a Policy | This form may be used in Delaware to satisfy the requirements of Delaware Insurance Regulation 606, with respect to notifications to be filed with the Delaware Division of Motor Vehicles. |
| IDENTIFICATION SECTION | Date | Enter the Month/day/year (MM/DD/YYYY) on which the form is completed. |
| IDENTIFICATION SECTION | State | Enter the state in which the Motor Vehicle bureau has jurisdiction. |
| Enter the name of the applicableinsurance company. Use the actual name of the | ||
| POLICY INFORMATION | Carrier | company within the group to which the policy has been issued. Do not use group names. |
| POLICY INFORMATION | NAIC Code | Enter the identification code assigned to the company by the NAIC. |
| POLICY INFORMATION | Effective Date | Enter the effective date shown in the policy. |
| POLICY INFORMATION | Expiration Date | Enter the expiration date shown in the policy. |
| POLICY INFORMATION | Termination Date | Enter the termination date of the policy. |
| POLICY INFORMATION | Policy Number | Enter the number exactly as it appears on the policy, including prefix and suffix symbols. |
| POLICY INFORMATION | Name of Agent | Enter the name of the agent (if applicable). |
| POLICYHOLDER | Enter the name and mailing address of the insured as found on the declarations page of | |
| INFORMATION | Policyholder Name and Address | the policy. |
| POLICYHOLDER | ||
| INFORMATION | Address 1 | Address 1 |
| POLICYHOLDER | ||
| INFORMATION | Address 2 | Address 2 |
| POLICYHOLDER | ||
| INFORMATION | City | City |
| POLICYHOLDER | ||
| INFORMATION | State | State |
| POLICYHOLDER | ||
| INFORMATION | Zip | Zip |
| REASON FOR POLICY | ||
| CANCELLATION OR | ||
| TERMINATION | Non-Payment of Premium | Check this box if the policy is being cancelled or terminated for non-payment of premium. |
| REASON FOR POLICY CANCELLATION OR TERMINATION | Policyholder Request | Check this box if the policy is being cancelled or terminated at the request of the policyholder. |
| REASON FOR POLICY CANCELLATION OR TERMINATION | Underwriting Reasons | Check this box if the policy is being cancelled or terminated for underwriting reasons. |
| REASON FOR POLICY CANCELLATION OR TERMINATION | Other | Check this box if the policy is being cancelled or terminated for a reason not stated above. Describe in the space provided. |
| REASON FOR POLICY CANCELLATION OR TERMINATION | Describe Other | Describe other reason. |
| REASON FOR POLICY CANCELLATION OR TERMINATION | Blank Area | Use this space for any additional comments or remarks. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| VEHICLE INFORMATION | Year | Enter the year of the motor vehicle. |
| VEHICLE INFORMATION | Make | Enter the make of the motor vehicle. |
| VEHICLE INFORMATION | Model | Enter the model of the motor vehicle. |
| VEHICLE INFORMATION | Vehicle Identification Number | Enter the vehicle Identification Number of the motor vehicle. |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | DMV Name and Address | Enter the name and address of the state agency receiving the cancellation/termination notice. |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | Address 1 | Address 1 |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | Address 2 | Address 2 |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | City | City |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | State | State |
| DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION | Zip | Zip |