                    CANCELLATION REQUEST / POLICY RELEASE        DATE __________

PRODUCER:  PHONE ___ ___ ____ EXT ____   INSURED NAME AND ADDRESS:
 _____________________________________   _______________________________________
 _____________________________________   _______________________________________
 _____________________________________   _______________________________________
 _____________________________________   _______________________________________
CODE: __________   SUBCODE: __________   AGENCY CUSTOMER ID: ___________________
                                         POLICY TYPE: __________________________
COMPANY NAME AND ADDRESS:                CANCELLED POLICY INFORMATION:
 _____________________________________   POLICY NUMBER _________________________
 _____________________________________   EFFECTIVE DATE _________ TIME _________
 _____________________________________   POLICY TERM    _________ TO   _________
 _____________________________________
 _ CANCELLATION REQUEST(POLICY ATTACHED)  _ POLICY RELEASE(COMPLETE STATEMENT)

                           POLICY RELEASE STATEMENT
    The undersigned agrees that:
         The above referenced policy is lost, destroyed or being retained.
         No claims of any type will be made against the Insurance Company,
         its agents or its representatives, under this policy for losses
         which occur after the date of cancellation shown above.
         Any premium adjustment will be made in accordance with the terms
         and conditions of the policy.

 ____________________________ ________   ______________________________ ________
 WITNESS                        DATE     SIGNATURE NAMED INSURED          DATE

 ____________________________ ________   ______________________________ ________
 WITNESS                        DATE     SIGNATURE NAMED INSURED          DATE

 _____________________________________   ______________________________ ________
 _ LIEN HOLDER _ MORTGAGEE _ LOSS PAYEE  AUTHORIZED SIGNATURE/TITLE       DATE

 _____________________________________   ______________________________ ________
 _ LIEN HOLDER _ MORTGAGEE _ LOSS PAYEE  AUTHORIZED SIGNATURE/TITLE       DATE

                            FOR AGENCY/COMPANY USE
        REASON FOR CANCELLATION                  METHOD OF CANCELLATION
 _ NOT TAKEN       _ OTHER(DESCRIBE)     _ FLAT        TERM PREMIUM   $ ________
 _ INSURED REQUEST ____________________  _ SHORT RATE  UNEARNED FACTOR  ________
 _ REWRITTEN       ____________________  _ PRO RATA    RETURN PREMIUM $ ________
COMPANY ______________________________
POLICY NUMBER ________________________   _ PREMIUM CALCULATION
EFFECTIVE DATE ________                    SUBJECT TO AUDIT
REMARKS ________________________________________________________________________
 _______________________________________________________________________________

NAME AND ADDRESS                         REQUEST/RELEASE DISTRIBUTION
 ______________________________________   _ INSURED     _ LOSS PAYEE
 ______________________________________   _ MORTGAGEE   _ LIEN HOLDER
 ______________________________________   _ COMPANY     _ FINANCE COMPANY

PRODUCER'S SIGNATURE _____________________________________________ DATE ________
