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I, _________________________________
(name), hereby request
that the following Policy _____________________ (number) be cancelled
effective ___________________ (Date).
The
udersigned 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 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 this
policy.
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