LCA Cancellation Request Form

Cancellation Request Form

California Low Cost Auto Insurance Program
Producer Name: Pacific Preferred Insurance

California License No. 0H55899

2775 N Ventura Road, Suite 110, Oxnard, CA 93036

800-913-1844

lowcostauto@pacificinsuresme.com
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If the email or phone number entered above differs from what we have on file, please note it below to prevent delays in processing.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the Mailing Address the same as the Physical Address?*

YesNo
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a Previous Address on File?*

YesNo
Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*

Integon National (Prefix IMPLC)21st Century (Prefix CAR)CAARP/AIO (Prefix AAP)Unknown (Not Assigned or Starts with 2)
Policy Number*
Policy Number*
Entry must be 11 digits | Reference Temp ID Card
Requested Cancellation Date*

MonthDayYear
Date must be in the future - there is no backdating allowed. Soonest Date Accepted is Date Following Submission.
Reason for Cancellation*

Inadequate Coverage ('Full Coverage' Needed or Higher Limits)Sold VehiclePlanned Nonoperation (PNO)OtherObtained Coverage ElsewherePricing
Terms of Use for Submission of Cancellation Form

By submitting this cancellation form and signing below, you acknowledge that the information provided is true to the best of your knowledge. You agree that we are not liable for forms not processed by us or the insurance company. It is your responsibility to follow up with our agency or the insurance company if you do not receive confirmation within 30 days.

Due to potential technology issues, such as submission errors, we are not responsible for forms that are not delivered. You must follow up to ensure successful submission. Submission of this form does not constitute confirmation or representation that your policy is currently active. In the event the insurance company determines that your policy is not active at the time this form is submitted, the request will be deemed null and void, and no further action will be taken.

The actual date of cancellation will be the day following the successful submission of the form to the insurance company, or a future date as indicated on the form. Backdating is not allowed.

If the information on this form does not match our records or if we cannot locate your account based on the provided details, this request may be disregarded. It is crucial that the information you provide is accurate and true.

When a Low Cost Auto Insurance policy is canceled, the premium refund will be calculated based on the pro rata unearned premium for the period of coverage, subject to a minimum premium of $50 per policy.

Hold Harmless and Release of Liability

By submitting this form, you agree to release and hold harmless our agency, its officers, agents, employees, and affiliates from any and all liability, claims, demands, or actions arising out of or related to the use or submission of this cancellation form, including but not limited to any issues related to the processing, delivery, or acceptance of the form by the insurance company. You acknowledge that it is your responsibility to ensure that all information provided is accurate, and to follow up on the status of your cancellation request if confirmation is not received within the specified time frame.
Signature*

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Electronic Signature Name:

First NameLast Name
Disclosure and Certification

Before this form is submitted to a carrier, it will be reviewed by a certified representative at Pacific Preferred Insurance Brokers LLC. The undersigned certifies and acknowledges that upon review by the agency representative, who is authorized to act on behalf of the company, the form will be submitted to the appropriate assigned carrier for the insured as indicated on the form. If the carrier is receiving this form, the undersigned further certifies that the representative has been authorized to act on behalf of the agency.

Kenneth Goodwin

President, Managing Partner

Pacific Preferred Insurance Brokers LLC

CA Lic 0H55844
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