Retired from cattle business
Resume:
RETURN
suspended. If your vehicle is still uninsured after 90 days, your driver's license will be suspended. To avoid these penalties, you must FINANCE COMPANY
DATE
CODE:
MORTGAGEE
$
METHOD OF CANCELLATION
UNEARNED
WITNESS
LOSS PAYEE
DATE
COMPANY NAME AND ADDRESS
TITLE
CANCELLATION DATE
POLICY RELEASE (Complete Statement Section Below)
REWRITTEN
HOUR OF CANCELLATION
New York Only: If you do not keep your auto insurance in force during the entire registration period, your motor vehicle registration will be PREMIUM
SIGNATURE OF NAMED INSURED
coverage to the Department of Motor Vehicles.
The above referenced policy is lost, destroyed or being retained. AGENCY
NOT TAKEN
COMPANY
REQUEST / RELEASE DISTRIBUTION
INSURED
SIGNATURE OF NAMED INSURED
PRODUCER
LIENHOLDER
PM
CANCELLATION REQUEST (Policy attached)
(Not applicable in NH per RSA 412:5 I)
EFFECTIVE DATE AND
(Complete below)
$
surrender your registration certificate and plates before your insurance expires. By law, we must report the termination of auto insurance REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED SIGNATURE
under this policy for losses which occur after the date of cancellation shown above. LOSS PAYEE
INSURED NAME AND ADDRESS
FACTOR
DATE
© 1988-2011 ACORD CORPORATION. All rights reserved. MORTGAGEE
WITNESS
NAIC CODE:
MORTGAGEE
DATE
POLICY RELEASE STATEMENT
EFFECTIVE DATE
PREMIUM CALCULATION
CANCELLATION REQUEST / POLICY RELEASE DATE (MM/DD/YYYY) No claims of any type will be made against the Insurance Company, its agents or its representatives, DATE
CUSTOMER ID:
This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act. OTHER (Identify)
ACORD 35 (2011/09)
EFFECTIVE DATE
DATE
COMPANY
LIENHOLDER
POLICY TYPE
LIENHOLDER
FULL TERM
REASON FOR CANCELLATION
PRO RATA
POLICY TERM
PRODUCER'S SIGNATURE
TITLE
Any premium adjustment will be made in accordance with the terms and conditions of the policy. AUTHORIZED SIGNATURE
POLICY NUMBER
FLAT
POLICY NUMBER
The ACORD name and logo are registered marks of ACORD DATE
(A/C, No, Ext):
The undersigned agrees that:
LOSS PAYEE
SUB CODE:
FOR AGENCY / COMPANY USE
PREMIUM
EXPIRATION DATE
NAME AND ADDRESS
SUBJECT TO AUDIT
PHONE
AM
(Not applicable in NH per RSA 412:5 I)
CANCELLED POLICY INFORMATION
REQUESTED BY INSURED
TIME
SHORT RATE
X
H01 0889241
X
12:01
07/16/21
07/16/2021
Homeowners
11/09/2021
BUCKJO2
Midland Empire Ins. Agency
527 Main St.
Klamath Falls, OR 97601
11/09/2020
10677
OP ID: DS
John & Patricia Buckmaster
3227 Pleasant Creek Road
Rogue River, OR 97537
X
1,126.00
X
X
07/16/21
John & Patricia Buckmaster
3227 Pleasant Creek Road
Rogue River, OR 97537
Cincinnati Insurance Company
P.O. Box 145496
Cincinnati, OH 45250-5496
Home sold
07/16/2021
ENV75314038-3392-ABAB-5906-CCDC
07/17/2021 00:01 AM UTC
Envelope Data
Buckmaster LPR.pdf
Subject: Home Policy H01 0889241
Documents:
Document Hash: 10569684
Envelope ID: ENV75314038-3392-ABAB-5906-CCDC
Sender: Debbie Schamp
Sent: 07/16/2021 23:52 PM UTC
Status: Completed
Status Date: 07/17/2021 00:01 AM UTC
Recipient(s) / Roles
Name / Role Address Type
Debbie Schamp ******@*******.*** Sender
John Buckmaster *************@******.*** Signer
Document Events
Name / Roles Email IP Address Date Event
Debbie Schamp ******@*******.*** 52.26.210.127 07/16/2021 23
:52 PM UTC Created
John Buckmaster *************@******.*** 24.156.96.72 07/17/2021 00
:01 AM UTC Signed
07/17/2021 00
:01 AM UTC Status - Completed
Signer Signatures
Signer Name / Roles Signature Initials
John Buckmaster
Contact this candidate