Section Name |
Field Name |
Field and/or Section Description |
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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. |
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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 |
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Enter the name and mailing address of the insured as found on the declarations page of |
INFORMATION |
Policyholder Name and Address |
the policy. |
POLICYHOLDER |
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INFORMATION |
Address 1 |
Address 1 |
POLICYHOLDER |
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INFORMATION |
Address 2 |
Address 2 |
POLICYHOLDER |
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INFORMATION |
City |
City |
POLICYHOLDER |
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INFORMATION |
State |
State |
POLICYHOLDER |
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INFORMATION |
Zip |
Zip |
REASON FOR POLICY |
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CANCELLATION OR |
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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 |