ACORD 58 Instructions


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