1027 - LCA Cancellation Request Form

Cancellation Request Form

California Low Cost Auto Insurance Program
Select Insurance Company for which the cancellation is being requested.*
Select your Integon National Policy Number prefix*
Policy Number - Integon National (IMPLC)*
Please enter the policy number for Integon National
Policy Number - Integon National (INT)*
Please enter the policy number for Integon National
Policy Number - Integon National
Policy Number - 21st Century*
Please enter the policy number for 21st Century
Policy Number - CAARP / AIO*
Please enter the policy number for CAARP / AIO
Policy Number - Other / Unsure*
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
Carrier PP
Policy number PP
Carrier-specific footer line (conditional)
Reason for Cancellation PP
Carrier Support and Email PP
Carrier select email des body
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
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. (Optional)
Email or Phone number
Mailing Address*

Street Address

Street Address Line 2

CityState

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

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState

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

YesNo
Previous Address*

Street Address

Street Address Line 2

CityState

Zip Code
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.
Electronic Signature Acknowledgement

By typing my name below and submitting this form, I acknowledge and agree that my typed name constitutes my electronic signature, carries the same legal effect as a handwritten signature, and confirms my request and authorization as stated above. I understand that this electronic signature, along with the recorded date/time and IP address, will be used to validate this submission.
Write your Full Name*
Signature*

Clear
Electronic Signature Name:

First NameLast Name
Submission DateTime [Hidden]
Disclosure and Certification

The undersigned, Pacific Preferred Insurance Brokers LLC, certifies that this request may have been submitted in one of two ways:
1. Direct Insured Submission:
  If the insured correctly selected the carrier and policy number in our self-service portal, this request may have been transmitted directly to the carrier without agency review, as a convenience to the insured.
2. Agency-Assisted Submission:
  If the insured did not know the carrier and/or policy number, an authorized agency representative reviewed and forwarded the request.
In all cases, the insured has been advised that no coverage, change, cancellation, or reinstatement is effective until confirmed in writing by the carrier.

Kenneth Goodwin
President, Managing Partner
Pacific Preferred Insurance Brokers LLC
CA Lic 0H55844
Should be Empty: