The ACORD name and logo are registered marks of ACORD

POLICY NUMBER

CANCELLED POLICY INFORMATION

EFFECTIVE DATE EXPIRATION DATE

POLICY TERM

EFFECTIVE DATE AND

HOUR OF CANCELLATION

PM

CANCELLATION DATE TIME AM

INSURED NAME AND ADDRESS

NAIC CODE:

POLICY TYPE

COMPANY NAME AND ADDRESS

AGENCY

CUSTOMER ID:

CODE: SUB CODE:

(A/C, No, Ext):

PRODUCER PHONE

CANCELLATION REQUEST / POLICY RELEASE DATE (MM/DD/YYYY) This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act.

(Not applicable in NH per RSA 412:5 I)

AUTHORIZED SIGNATURE TITLE DATE

CANCELLATION REQUEST POLICY RELEASE (Complete SIGNATURES section below)

(Policy attached)

Any premium adjustment will be made in accordance with the terms and conditions of the policy. under this policy for losses which occur after the date of cancellation shown above. No claims of any type will be made against the Insurance Company, its agents or its representatives, The above referenced policy is lost, destroyed or being retained. The undersigned agrees that:

WITNESS DATE

WITNESS DATE

SIGNATURE OF NAMED INSURED DATE

SIGNATURE OF NAMED INSURED DATE

LIENHOLDER MORTGAGEE LOSS PAYEE

(Not applicable in NH per RSA 412:5 I)

AUTHORIZED SIGNATURE TITLE DATE

ACORD 35 (2017/05) © 1988-2017 ACORD CORPORATION. All rights reserved. FOR AGENCY / COMPANY USE

New York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will be suspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To avoid these penalties, you must surrender your registration certificate and plates before your insurance expires. By law, we must report the termination of auto insurance coverage to the Department of Motor Vehicles.

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) POLICY NUMBER EFFECTIVE DATE

COMPANY

SUBJECT TO AUDIT

PREMIUM CALCULATION

PRO RATA

SHORT RATE

FLAT

PREMIUM $

RETURN

FACTOR

UNEARNED

PREMIUM $

FULL TERM

METHOD OF CANCELLATION

OTHER (Identify)

(Complete below)

REWRITTEN

REQUESTED BY INSURED

NOT TAKEN

REASON FOR CANCELLATION

PRODUCER'S SIGNATURE DATE

NAME AND ADDRESS REQUEST / RELEASE DISTRIBUTION

FINANCE COMPANY

LIENHOLDER

LOSS PAYEE

COMPANY

MORTGAGEE

INSURED

LENDER'S LOSS PAYABLE

LIENHOLDER MORTGAGEE LOSS PAYEE LENDER'S LOSS PAYABLE LENDER'S LOSS PAYABLE

SIGNATURES

01/13/2023

DUNN INSURANCE INC

198 S MAIN STREET

MIDDLETOWN CT 06457

NATIONWIDE

AUTO AND RENTERS

BENJAMIN PEREZ

149 HUNTINGTON ST APT 324

NEW LONDON CT 06320

5106L054197 & 5106hs006095

01/13/2023

PAULINE MAUDSLEY 01/13/2023

Electronically Signed 2023-01-13 19:47:06 UTC - 32.219.224.134 Nintex AssureSign® 7ae375ee-0708-4c23-95a7-af890143bd4f 1/13/2023

Contact this candidate