PRODUCER'S NAME & ADDRESS
SEGUROS UNIVERSAL INC DBA ATL INSURANCE 3573 CLAIRMONT RD BROOKHEAVEN GA 30319
AGENCY'S PHONE NUMBER
CANCELLATION REQUEST FORM
POLICY RELEASE
POLICY HOLDER INFORMATION
Insured's Name
*
DATE (MM/DD/YYYY)
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
POLICY INFORMATION
Coverage to be cancelled
Type of Insurance
*
Automobile
Homeowners
Renters
Motorcycle
Commercial General Liability
Business Owners Package
Worker's Compensation
Commercial Umbrella/Excess
Insurance Company Name
*
ACCC Insurance Company
Aegis Security Insurance Company
Aetna Health Inc.
Aetna Health Insurance Company
Aetna Life Insurance Company
Alpha Property & Casualty Insurance Company
AssuranceAmerica Insurance Company
Blue Cross and Blue Shield of Georgia, Inc.
Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
Century-National Insurance Company
Charter Indemnity Company
Coast National Insurance Company
Coventry Health and Life Insurance Company
Coventry Health Care of Georgia, Inc.
Dairyland Insurance Company
Ethio-American Insurance Company
Everest Security Insurance Company
Farmers Insurance Exchange
Farmers New World Life Insurance Company
Foremost Insurance Company Grand Rapids, Michigan
Foremost Property and Casualty Insurance Company
Foremost Signature Insurance Company
Greater Georgia Life Insurance Company
Heritage Property & Casualty Insurance Company
Homesite Insurance Company
Humana Employers Health Plan of Georgia, Inc.
Humana Insurance Company
Humanadental Insurance Company
Infinity Auto Insurance Company
Infinity Casualty Insurance Company
Infinity Insurance Company
Infinity Select Insurance Company
InsureMax Insurance Company
Kanawha Insurance Company
National Interstate Insurance Company
Omni Indemnity Company
Patriot General Insurance Company
Peak Property and Casualty Insurance Corporation
Permanent General Assurance Corporation
Primerica Life Insurance Company
Progressive American Insurance Company
Progressive Bayside Insurance Company
Progressive Classic Insurance Company
Progressive Mountain Insurance Company
Progressive Preferred Insurance Company
RLI Insurance Company
Safeway Insurance Company of Georgia
Southern General Insurance Company
Stonebridge Life Insurance Company
The Automobile Insurance Company of Hartford, Connecticut
The Charter Oak Fire Insurance Company
The Phoenix Insurance Company
The Standard Fire Insurance Company
The Travelers Home and Marine Insurance Company
The Travelers Indemnity Company
The Travelers Indemnity Company of America
Time Insurance Company
Titan Indemnity Company
Transamerica Life Insurance Company
Travco Insurance Company
Travelers Casualty and Surety Company
Travelers Property Casualty Company of America
Travelers Property Casualty Insurance Company
Trexis One Insurance Corporation
Triumphe Casualty Company
United Automobile Insurance Company
Universal Property & Casualty Insurance Company
Victoria Fire and Casualty Company
Victoria Select Insurance Company
Victoria Specialty Insurance Company
Western Surety Company
Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
POLICY NUMBER
*
CANCELLATION EFFECTIVE DATE
CANCELLATION DATE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
REASON FOR CANCELLATION
(Complete below)
OTHER (Identify)
NOT TAKEN
REQUESTED BY INSURED
REWRITTEN
POLICY RELEASE STATEMENT
The undersigned agrees that: The above referenced policy is lost, destroyed, or being retained. No claims of any type will be made against the Insurance Company, its agents, or its representatives, under this policy for losses which occur after the date of cancellation shown above. Any premium adjustment will be made in accordance with the terms and conditions of the policy.
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
WITNESS
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is there another named insured?
*
Yes
No
Second Named Insured Signature (If any)
Second Named Insured (if any)
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
© 1988-2010 ACORD CORPORATION. All rights reserved.
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