ACORD 35 (2011/09)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 35 (2011/09)
Cancellation Request / Policy
Release
ACORD 35, Cancellation Request / Policy Release form explains
information the company needs to process the transaction.
This form is used as tangible evidence of the insured's instruction to cancel a contract. It
can be used for either Personal or Commercial Lines, or as an enclosure to the returned
original contract, when available.
* Method of cancellation and all calculations should be confirmed with the company before
final settlement of the account with the insured. Caution should be exercised to ensure
proper signature specifications are followed, as required by the company.
Insured entities must have an authorized signature and title where applicable. Individual
companies may have specific requirements for additional information particularly in
situations of Policy Rewritten or Pro Rata cancellations.
Verify that cancellation notice rights have not been extended to additional parties.
Premium financed policies should be discreetly handled to ensure proper transmittal of
premium and information.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Name
Enter Text: The producer of record whose policy is being cancelled.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
ACORD 35 (2011/09) rev. 08-29-2011
1 of 9
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Company Name and Address
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
Enter text: The first line of the insurer's mailing address.
IDENTIFICATION SECTION
Enter text: The second line of the insurer's mailing address.
IDENTIFICATION SECTION
Enter text: The city of the insurer's mailing address.
IDENTIFICATION SECTION
Enter code: The state or province of the insurer's mailing address.
IDENTIFICATION SECTION
Enter code: The postal code of the insurer's mailing address.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Policy Type
Enter text: The type of policy issued to the insured (e. g., personal auto, truckers, garage
liability, commercial property, builders risk, etc.).
IDENTIFICATION SECTION Insured Name and Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
ACORD 35 (2011/09) rev. 08-29-2011
2 of 9
Section Name
Field Name
Field and/or Section Description
CANCELLED POLICY
INFORMATION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
CANCELLED POLICY
INFORMATION
Cancellation Date
Enter date: The effective date of the cancellation or non renewal.
CANCELLED POLICY
INFORMATION
Time
Enter time: The effective time of the cancellation or non renewal.
CANCELLED POLICY
INFORMATION
AM
Check the box (if applicable): Indicates the effective time of the cancellation is in the
morning (AM).
CANCELLED POLICY
INFORMATION
PM
Check the box (if applicable): Indicates the effective time of the cancellation is in the
afternoon or evening (PM).
CANCELLED POLICY
INFORMATION
Policy Term Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
CANCELLED POLICY
INFORMATION
Policy Term Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
POLICY RELEASE
(Complete Statement
Section below)
Cancellation Request
Check the box (if applicable): Indicates this is a cancellation request.
POLICY RELEASE
(Complete Statement
Section below)
Policy Release
Check the box (if applicable): Indicates this is a policy release statement. When this
document is used as a Policy Release, an insured should have a witness sign
and date the form before returning it to the agent.
POLICY RELEASE
(Complete Statement
Section below)
Witness One
Sign here: The signature of the witness to the form. As used here, when this document is
used as a Policy Release, an insured should have a witness sign and date the form before
returning it to the agent.
POLICY RELEASE
(Complete Statement
Section below)
Date One
Enter date: The date the witness signed the form.
POLICY RELEASE
(Complete Statement
Section below)
Signature of Named Insured One
Sign here: Accommodates the signature of the applicant or named insured. As used here,
the first named insured must sign and date this form when used as either a Cancellation
Request or Policy Release.
POLICY RELEASE
(Complete Statement
Section below)
Date Two
Enter date: The date the form was signed by the named insured.
POLICY RELEASE
(Complete Statement
Section below)
Witness Two
Sign here: The signature of the witness to the form.
ACORD 35 (2011/09) rev. 08-29-2011
3 of 9
Section Name
Field Name
Field and/or Section Description
POLICY RELEASE
(Complete Statement
Section below)
Date Three
Enter date: The date the witness signed the form.
POLICY RELEASE
(Complete Statement
Section below)
Signature of Named Insured Two
Sign here: Accommodates the signature of the applicant or named insured.
POLICY RELEASE
(Complete Statement
Section below)
Date Four
Enter date: The date the form was signed by the named insured.
POLICY RELEASE
(Complete Statement
Section below)
Additional Interest Name &
Address
Enter text: The additional interest's full name. As used here, provide the name and
address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking X
in the appropriate box. The signature and title of an authorized representative of any
additional interest indicated in the contract must be obtained if the document is used as a
Policy Release. Space is provided for the corresponding signature date.
POLICY RELEASE
(Complete Statement
Section below)
Enter text: The additional interest's mailing address line one.
POLICY RELEASE
(Complete Statement
Section below)
Enter text: The additional interest's mailing address city name.
POLICY RELEASE
(Complete Statement
Section below)
Enter code: The additional interest's mailing address state or province code.
POLICY RELEASE
(Complete Statement
Section below)
Enter code: The additional interest's mailing address postal code.
POLICY RELEASE
(Complete Statement
Section below)
Lienholder One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
POLICY RELEASE
(Complete Statement
Section below)
Mortgagee One
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
POLICY RELEASE
(Complete Statement
Section below)
Loss Payee One
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ACORD 35 (2011/09) rev. 08-29-2011
4 of 9
Section Name
Field Name
Field and/or Section Description
POLICY RELEASE
(Complete Statement
Section below)
Authorized Signature One
Sign here: Accommodates the signature of the additional interest or authorized
representative.
POLICY RELEASE
(Complete Statement
Section below)
Title One
Enter text: The title of the additional interest's authorized representative.
POLICY RELEASE
(Complete Statement
Section below)
Date Five
Enter date: The date the form was signed by the additional interest.
POLICY RELEASE
(Complete Statement
Section below)
Additional Interest Name &
Address
Enter text: The additional interest's full name.
POLICY RELEASE
(Complete Statement
Section below)
Enter text: The additional interest's mailing address line one.
POLICY RELEASE
(Complete Statement
Section below)
Enter text: The additional interest's mailing address city name.
POLICY RELEASE
(Complete Statement
Section below)
Enter code: The additional interest's mailing address state or province code.
POLICY RELEASE
(Complete Statement
Section below)
Enter code: The additional interest's mailing address postal code.
POLICY RELEASE
(Complete Statement
Section below)
Lienholder Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
POLICY RELEASE
(Complete Statement
Section below)
Mortgagee Two
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
POLICY RELEASE
(Complete Statement
Section below)
Loss Payee Two
Check the box (if applicable): Indicates the additional interest type is a loss payee.
POLICY RELEASE
(Complete Statement
Section below)
Authorized Signature Two
Sign here: Accommodates the signature of the additional interest or authorized
representative.
ACORD 35 (2011/09) rev. 08-29-2011
5 of 9
Section Name
Field Name
Field and/or Section Description
POLICY RELEASE
(Complete Statement
Section below)
Title Two
Enter text: The title of the additional interest's authorized representative.
POLICY RELEASE
(Complete Statement
Section below)
Date Six
Enter date: The date the form was signed by the additional interest.
FOR AGENCY / COMPANY Reason for Cancellation - Not
USE
Taken
Check the box (if applicable): Indicates the policy is being cancelled because it was not
taken.
FOR AGENCY / COMPANY
USE
Requested by Insured
Check the box (if applicable): Indicates the policy is being cancelled due to the insured's
request.
FOR AGENCY / COMPANY
USE
Rewritten
Check the box (if applicable): Indicates the policy is being cancelled because it was
rewritten. If rewritten is indicated,
enter the new company, policy number, and effective date in the spaces provided. As
used here, If rewritten is indicated, enter the new Company, Policy Number, and Inception
Date in the spaces provided.
FOR AGENCY / COMPANY
USE
Other
Check the box (if applicable): Indicates the policy is being cancelled due to reasons other
than those listed. As used here, if Other is indicated, identify the reason in the space
provided.
FOR AGENCY / COMPANY
USE
Other Description
Enter text: The description of why the policy is being cancelled or terminated.
FOR AGENCY / COMPANY
USE
Company
Enter text: The full name of the new insurer when the policy is being cancelled because
the insured found other insurance. As used here, the name of the company that the
rewritten policy has been placed with.
FOR AGENCY / COMPANY
USE
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number. As used here, the
new policy number for the rewritten policy.
FOR AGENCY / COMPANY
USE
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the effective date of the rewritten policy.
ACORD 35 (2011/09) rev. 08-29-2011
6 of 9
Section Name
Field Name
Field and/or Section Description
FOR AGENCY / COMPANY
USE
Method of Cancellation - Flat
Check the box (if applicable): Indicates the cancellation method being used is flat. Note:
Individual companies may have specific requirements for additional information,
particularly in situations of rewritten or pro-rata cancellations. The method of cancellation
and all calculations should be confirmed with the company before final settlement of the
account with the insured. As used here, Note: Individual companies may have specific
requirements for additional information, particularly in situations of rewritten or pro-rata
cancellations. The method of cancellation and all calculations should be confirmed with
the company before final settlement of the account with the insured.
FOR AGENCY / COMPANY
USE
Short Rate
Check the box (if applicable): Indicates the cancellation method being used is short rate.
Note: Individual companies may have specific requirements for additional information,
particularly in situations of rewritten or pro-rata cancellations. The method of cancellation
and all calculations should be confirmed with the company before final settlement of the
account with the insured.
FOR AGENCY / COMPANY
USE
Pro Rata
Check the box (if applicable): Indicates the cancellation method being used is pro rata.
Note: Individual companies may have specific requirements for
additional information, particularly in situations of rewritten or pro-rata cancellations. The
method of cancellation and all calculations should be confirmed with the company before
final settlement of the account with the insured.
FOR AGENCY / COMPANY Premium Calculation Subject to
USE
Audit
Check the box (if applicable): Indicates the premium calculation is subject to audit.
FOR AGENCY / COMPANY
USE
Full Term Premium
Enter amount: The premium for the full term (six months, annual, etc.) of the policy,
including endorsements.
FOR AGENCY / COMPANY
USE
Unearned Factor
Enter percentage: The unearned factor from either the short rate or pro-rata tables for the
unearned period of
time; from date of cancellation to date of policy expiration.
FOR AGENCY / COMPANY
USE
Return Premium
Enter amount: The gross return premium equals the unearned factor multiplied by the full
term premium.
FOR AGENCY / COMPANY
USE
Remarks
Enter text: The remarks associated with the cancellation or non-renewal. As used here,
list any additional comments regarding the cancellation. Explanations should be made
regarding back-dated cancellations or why premium is listed as being pro-rated instead of
short-rated.
ACORD 35 (2011/09) rev. 08-29-2011
7 of 9
Section Name
Field Name
Field and/or Section Description
NAME AND ADDRESS
Name and Address
Enter text: The full name of the party receiving a copy of the cancellation request/policy
release form. As used here, use these sections to list any additional distributions for this
form, including the new agent of record, if any. Check the appropriate box for the
corresponding address. The line within the name and address field is a margin setting
used for window envelopes.
NAME AND ADDRESS
Enter text: The first address line of the party receiving a copy of the cancellation
request/policy release form.
NAME AND ADDRESS
Enter text: The second address line of the party receiving a copy of the cancellation
request/policy release form.
NAME AND ADDRESS
Enter text: The city of the party receiving a copy of the cancellation request/policy release
form.
NAME AND ADDRESS
Enter code: The state or province code of the party receiving a copy of the cancellation
request/policy release form.
NAME AND ADDRESS
Enter code: The postal code of the party receiving a copy of the cancellation
request/policy release form.
REQUEST / RELEASE
DISTRIBUTION
Insured
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the insured.
REQUEST / RELEASE
DISTRIBUTION
Loss Payee
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the loss payee.
REQUEST / RELEASE
DISTRIBUTION
Mortgagee
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the mortgagee.
REQUEST / RELEASE
DISTRIBUTION
Lienholder
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the lienholder.
REQUEST / RELEASE
DISTRIBUTION
Company
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the company.
REQUEST / RELEASE
DISTRIBUTION
Finance Company
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to the finance company.
REQUEST / RELEASE
DISTRIBUTION
Other Distribution One
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to someone other than those listed.
REQUEST / RELEASE
DISTRIBUTION
Describe Other Distribution One
Enter text: The description of the party that should receive a copy of the cancellation
request/policy release statement.
REQUEST / RELEASE
DISTRIBUTION
Other Distribution Two
Check the box (if applicable): Indicates a copy of the cancellation request/policy release
should be sent to someone other than those listed.
REQUEST / RELEASE
DISTRIBUTION
Describe Other Distribution Two
Enter text: The description of the party that should receive a copy of the cancellation
request/policy release statement.
ACORD 35 (2011/09) rev. 08-29-2011
8 of 9
Section Name
Field Name
Field and/or Section Description
PRODUCERS SIGNATURE Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
PRODUCERS SIGNATURE Date
Enter date: The date the producer signed the form.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 35 (2011/09) rev. 08-29-2011
9 of 9