Wealth Management May Be
Resume:
MLM
CrossStone Insurance & Wealth Management, Inc.
Piney Flats, TN 37686
006451
00000931
American Modern
PO Box 5323
Cincinnati, OH 45201
42722
Homeowners: MH
GERALD DOUTT
115 Aa Dekins Rd
Jonesbough, TN 37659
01/25/2024 12:01
X
03/20/2023 03/20/2024
X
X
GERALD DOUTT
115 Aa Dekins Rd
Jonesbough, TN 37659
X
Printed by MLM on January 29, 2024 at 12:14PM
DATE (MM/DD/YYYY)
PRODUCER (PHONE A/C, No, Ext): COMPANY NAME AND ADDRESS NAIC CODE: CODE: SUB CODE: POLICY TYPE
AGENCY
CUSTOMER ID:
INSURED NAME AND ADDRESS
POLICY NUMBER
EFFECTIVE DATE AND CANCELLATION DATE TIME
HOUR OF CANCELLATION
EFFECTIVE DATE EXPIRATION DATE
POLICY TERM
WITNESS DATE SIGNATURE OF NAMED INSURED DATE
WITNESS DATE SIGNATURE OF NAMED INSURED DATE
AUTHORIZED SIGNATURE TITLE DATE
(Not applicable in NH per RSA 412:5 I)
AUTHORIZED SIGNATURE TITLE DATE
(Not applicable in NH per RSA 412:5 I)
FULL PREMIUM TERM $
COMPANY
UNEARNED
FACTOR
POLICY NUMBER EFFECTIVE DATE
RETURN PREMIUM $
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PRODUCER'S SIGNATURE DATE
AM
PM
LIENHOLDER MORTGAGEE LOSS PAYEE LENDER'S LOSS PAYABLE LIENHOLDER MORTGAGEE LOSS PAYEE LENDER'S LOSS PAYABLE NOT TAKEN OTHER (Identify)
REQUESTED BY INSURED FLAT
REWRITTEN (Complete below) SHORT RATE
PRO RATA
PREMIUM CALCULATION
SUBJECT TO AUDIT
INSURED LOSS PAYEE LENDER'S LOSS PAYABLE
MORTGAGEE LIENHOLDER
COMPANY FINANCE COMPANY
The undersigned agrees that:
The above referenced policy is lost, destroyed or being retained. No claims of any type will be made against the Insurance Company, its agents or its representatives, under this policy for losses which occur after the date of cancellation shown above. Any premium adjustment will be made in accordance with the terms and conditions of the policy. This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act. CANCELLED POLICY INFORMATION
CANCELLATION REQUEST
(Policy attached)
POLICY RELEASE (Complete SIGNATURES section below) SIGNATURES
FOR AGENCY / COMPANY USE
REASON FOR CANCELLATION METHOD OF CANCELLATION
NAME AND ADDRESS REQUEST / RELEASE DISTRIBUTION
ACORD 35 (2017/05) © 1988-2017 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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.
CANCELLATION REQUEST / POLICY RELEASE
01/29/2024
Encyro E-Sign ID: 7e46f417542e47b09f504482faa63a77 (2024-Jan-29 17:25:13 UTC) Audit Trail
Tamper Verification
To check if this file has been modified after being signed, please go to: https://www.encyro.com/esign/verify
Upload the file. The result will indicate if the file contents have been tampered with. Signed By
Signer: ***********@******.***
Identity Check: Email Authentication
Signature Type: Mouse or hand drawn
Time Zone: UTC-05:00, America/New York (Eastern Standard Time) Event Log
Jan 29, 2024, 12:16:48 PM - Email notification sent to ***********@******.***. Jan 29, 2024, 12:16:54 PM - Email notification delivered to ***********@******.***. Jan 29, 2024, 12:17:05 PM - ***********@******.*** opened the email notification (estimated). Jan 29, 2024, 12:25:07 PM - ***********@******.*** electronically signed or completed the document, from 35.150.222.108. END OF LOG
Contact this candidate