Customer Service Financial Services
Resume:
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 attached) POLICY RELEASE (Complete Statement Section Below) 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:
POLICY RELEASE STATEMENT
WITNESS DATE
WITNESS DATE
SIGNATURE OF NAMED INSURED DATE
SIGNATURE OF NAMED INSURED DATE
LIENHOLDER MORTGAGEE LOSS PAYEE
LIENHOLDER MORTGAGEE LOSS PAYEE
(Not applicable in NH per RSA 412:5 I)
AUTHORIZED SIGNATURE TITLE DATE
ACORD 35 (2011/09) © 1988-2011 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
02/13/2023
Spencer Insurance Group
2420 Sandcreek Road
C-3 Suite 150
Brentwood CA 94513
200009
Allstate
36455
Personal Auto
Austin W Cisneros
700 Rocky Creek Ter
BRENTWOOD CA 94513
999732700
02/08/2023
02/08/2023 08/08/2023
02/13/2023
Insured no longer owns vehicle and policy should not have been renewed. Austin Cisneros (Feb 24, 2023 12:24 PST) Feb 24, 2023 Signature:
Email:
Title:
Austin Cisneros (Feb 24, 2023 12:24 PST)
******************@*****.***
Spice operations worker
CancellationRequestPolicyRelease
Final Audit Report 2023-02-24
Created: 2023-02-14
By: Jason Spencer (********@*********************.***) Status: Signed
Transaction ID: CBJCHBCAABAANo4QhIY5V3Z6y8qEZ8FE2jZMnEmORNqQ
"CancellationRequestPolicyRelease" History
Document created by Jason Spencer (********@*********************.***) 2023-02-14 - 5:41:36 AM GMT- IP address: 172.59.9.34 Document emailed to *****************@*****.*** for signature 2023-02-14 - 5:42:26 AM GMT
Email viewed by *****************@*****.***
2023-02-14 - 7:52:21 AM GMT- IP address: 104.28.116.87 Email viewed by *****************@*****.***
2023-02-17 - 4:17:30 PM GMT- IP address: 104.28.124.108 Email viewed by *****************@*****.***
2023-02-19 - 4:48:46 PM GMT- IP address: 104.28.123.106 Email viewed by *****************@*****.***
2023-02-21 - 6:43:32 AM GMT- IP address: 172.225.88.141 Email viewed by *****************@*****.***
2023-02-22 - 5:07:49 AM GMT- IP address: 104.28.123.94 Email viewed by *****************@*****.***
2023-02-24 - 6:20:36 AM GMT- IP address: 104.28.123.97 Jason Spencer (********@*********************.***) replaced signer *****************@*****.*** with ******************@*****.*** 2023-02-24 - 3:45:54 PM GMT- IP address: 172.59.9.34 Document emailed to ******************@*****.*** for signature 2023-02-24 - 3:45:54 PM GMT
Email viewed by ******************@*****.***
2023-02-24 - 8:19:03 PM GMT- IP address: 172.226.212.5 Signer ******************@*****.*** entered name at signing as Austin Cisneros 2023-02-24 - 8:24:42 PM GMT- IP address: 172.59.129.220 Document e-signed by Austin Cisneros (******************@*****.***) Signature Date: 2023-02-24 - 8:24:44 PM GMT - Time Source: server- IP address: 172.59.129.220 Agreement completed.
2023-02-24 - 8:24:44 PM GMT
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