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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/07/2008. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 58 (2007/11) |
Notice of Cancellation or Termination of a Policy |
The title of the form. Use ACORD 58, Notice of Cancellation or Termination of a Policy, whenever it is necessary to notify a state motor vehicle bureau that an insurance policy is being cancelled or terminated, and no specific notice form is required. This form may be used in Delaware to satisfy the requirements of Delaware Insurance Regulation 606, with respect to notifications to be filed with the Delaware Division of Motor Vehicles. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
State |
Enter code: The state which has jurisdiction over the policy. |
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POLICY INFORMATION |
Carrier |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. This is not the insurer's group name or trade name. |
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POLICY INFORMATION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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POLICY INFORMATION |
Effective Date |
Enter date: The effective date of the policy. |
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POLICY INFORMATION |
Expiration Date |
Enter date: The date on which the terms and conditions of the policy will expire. |
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POLICY INFORMATION |
Termination Date |
Enter date: The effective date of the cancellation or non renewal. |
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POLICY INFORMATION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. |
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POLICY INFORMATION |
Name of Agent |
Enter text: The producer's full name. |
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POLICYHOLDER INFORMATION |
Policyholder Name and Address |
Enter text: The named insured’s full name as it appears on the policy declarations page. |
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POLICYHOLDER INFORMATION |
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Enter text: The named insured's mailing address line one. |
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POLICYHOLDER INFORMATION |
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Enter text: The named insured's mailing address line two. |
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POLICYHOLDER INFORMATION |
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Enter text: The named insured's mailing address city name. |
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POLICYHOLDER INFORMATION |
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Enter code: The named insured's mailing address state or province code. |
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POLICYHOLDER INFORMATION |
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Enter code: The named insured's mailing address postal code. |
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Section Name |
Field Name |
Field and/or Section Description |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Non-Payment of Premium |
Check the box (if applicable): Indicates the policy is being cancelled due to non-payment of premium. |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Policyholder Request |
Check the box (if applicable): Indicates the policy is being cancelled due to the insured's request. |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Underwriting Reasons |
Check the box (if applicable): Indicates the policy is being cancelled due to underwriting reasons. |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Other |
Check the box (if applicable): Indicates the policy is being cancelled due to reasons other than those listed. |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Describe Other |
Enter text: The description of why the policy is being cancelled or terminated. |
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REASON FOR POLICY CANCELLATION OR TERMINATION |
Blank Area |
Enter text: The remarks associated with the cancellation or non-renewal. |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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Section Name |
Field Name |
Field and/or Section Description |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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VEHICLE INFORMATION |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE INFORMATION |
Vehicle Identification Number |
Enter identifier: The vehicle identification number (VIN). |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
DMV Name and Address |
Enter text: The name of the department of motor vehicles. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter text: The name of the contact person or department within the department of motor vehicles. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter text: The DMV's mailing address first address line. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter text: The DMV's mailing address second address line. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter text: The DMV's mailing address city name. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter code: The DMV's mailing address state or province. |
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DEPARTMENT / DIVISION OF MOTOR VEHICLES INFORMATION |
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Enter code: The DMV's mailing address postal code. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |