Cancellation Request
	Insurer:
	Policy Number:
	Insured(s):
	Effective Date:
	I/We agree that the Policy indicated by number above and/or renewal certificate (if any) relating thereto are cancelled as of the Effective Date stated above and that the Insurer is relieved from all liability thereunder from the said date. I/We also agree that any premium adjustment will be made in accordance with the terms and conditions of the Policy.