Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/07/2008.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 58 (2007/11)
Notice of Cancellation or
Termination of a Policy
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.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION State
Enter code: The state which has jurisdiction over the policy.
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.
POLICY INFORMATION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
POLICY INFORMATION
Effective Date
Enter date: The effective date of the policy.
POLICY INFORMATION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
POLICY INFORMATION
Termination Date
Enter date: The effective date of the cancellation or non renewal.
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.
POLICY INFORMATION
Name of Agent
Enter text: The producer's full name.
POLICYHOLDER
INFORMATION
Policyholder Name and Address
Enter text: The named insureds full name as it appears on the policy declarations page.
POLICYHOLDER
INFORMATION
Enter text: The named insured's mailing address line one.
POLICYHOLDER
INFORMATION
Enter text: The named insured's mailing address line two.
POLICYHOLDER
INFORMATION
Enter text: The named insured's mailing address city name.
POLICYHOLDER
INFORMATION
Enter code: The named insured's mailing address state or province code.
POLICYHOLDER
INFORMATION
Enter code: The named insured's mailing address postal code.
ACORD 58 (2007/11)
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Section Name
Field Name
Field and/or Section Description
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.
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.
REASON FOR POLICY
CANCELLATION OR
TERMINATION
Underwriting Reasons
Check the box (if applicable): Indicates the policy is being cancelled due to underwriting
reasons.
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.
REASON FOR POLICY
CANCELLATION OR
TERMINATION
Describe Other
Enter text: The description of why the policy is being cancelled or terminated.
REASON FOR POLICY
CANCELLATION OR
TERMINATION
Blank Area
Enter text: The remarks associated with the cancellation or non-renewal.
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
ACORD 58 (2007/11)
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Section Name
Field Name
Field and/or Section Description
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
VEHICLE INFORMATION
Year
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Vehicle Identification Number
Enter identifier: The vehicle identification number (VIN).
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
DMV Name and Address
Enter text: The name of the department of motor vehicles.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter text: The name of the contact person or department within the department of motor
vehicles.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter text: The DMV's mailing address first address line.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter text: The DMV's mailing address second address line.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter text: The DMV's mailing address city name.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter code: The DMV's mailing address state or province.
DEPARTMENT / DIVISION
OF MOTOR VEHICLES
INFORMATION
Enter code: The DMV's mailing address postal code.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 58 (2007/11)
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