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ACORD Form 35 Cancellation
Request/Policy Release Instructions

 

 
ACORD 35 (1/97) 1 of 9
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
TITLE ACORD 35 (1/97) CANCELLATION REQUEST / POLICY RELEASE The title of the form. 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 Producer Enter text: The full name of the producer/agency.
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 (1/97) 2 of 9
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
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.
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 (1/97) 3 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
CANCELED 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.
CANCELED POLICY INFORMATION Cancellation Date Enter date: The effective date of the cancellation or non renewal.
CANCELED POLICY INFORMATION Time Enter time: The effective time of the cancellation or non renewal.
CANCELED POLICY INFORMATION AM Check the box (if applicable): Indicates the effective time of the cancellation is in the morning (AM).
CANCELED POLICY INFORMATION PM Check the box (if applicable): Indicates the effective time of the cancellation is in the afternoon or evening (PM).
CANCELED 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.
CANCELED 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.

ACORD 35 (1/97) 4 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
POLICY RELEASE (Complete Statement Section below) Witness Two Sign here: The signature of the witness to the form.
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) Lien Holder One Check the box (if applicable): Indicates the additional interest type is a lien holder.

ACORD 35 (1/97) 5 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
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.
POLICY RELEASE (Complete Statement Section below) Authorized Signature One Sign here: Accommodates the signature of the additional interest.
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) Lien Holder Two Check the box (if applicable): Indicates the additional interest type is a lien holder.

ACORD 35 (1/97) 6 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
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.
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 USE Reason for Cancellation - Not 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.

ACORD 35 (1/97) 7 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
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.
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 USE Premium Calculation Subject to 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.

ACORD 35 (1/97) 8 of 9

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
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.
NAME AND ADDRESS -Request/ Release Distribution 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 -Request/ Release Distribution Enter text: The first address line of the party receiving a copy of the cancellation request/policy release form.
NAME AND ADDRESS -Request/ Release Distribution Enter text: The second address line of the party receiving a copy of the cancellation request/policy release form.
NAME AND ADDRESS -Request/ Release Distribution Enter text: The city of the party receiving a copy of the cancellation request/policy release form.
NAME AND ADDRESS -Request/ Release Distribution Enter code: The state or province code of the party receiving a copy of the cancellation request/policy release form.
NAME AND ADDRESS -Request/ Release Distribution Enter code: The postal code of the party receiving a copy of the cancellation request/policy release form.
NAME AND ADDRESS -Request/ Release Distribution Insured Check the box (if applicable): Indicates a copy of the cancellation request/policy release should be sent to the insured.
NAME AND ADDRESS -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.
NAME AND ADDRESS -Request/ Release Distribution Mortgagee Check the box (if applicable): Indicates a copy of the cancellation request/policy release should be sent to the mortgagee.
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
Section Name Field Name Field and/or Section Description
NAME AND ADDRESS -Request/ Release Distribution Lien Holder Check the box (if applicable): Indicates a copy of the cancellation request/policy release should be sent to the lienholder.
NAME AND ADDRESS -Request/ Release Distribution Company Check the box (if applicable): Indicates a copy of the cancellation request/policy release should be sent to the company.
NAME AND ADDRESS -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.
NAME AND ADDRESS -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.
NAME AND ADDRESS -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.
NAME AND ADDRESS -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.
NAME AND ADDRESS -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.
PRODUCERíS SIGNATURE Producers 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.
PRODUCERíS 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 (1/97) 9 of 9