ACORD 35 Fillable PDF | Policy Release / Cancellation Form

It’s the ACORD cancellation form people use to cancel an insurance policy in writing. The full name is Cancellation Request / Policy Release. The insured signs it, the agent sends it to the insurance company, and the company keeps it as proof that the insured asked to end the policy.

The form works on personal and commercial policies. It also does a second job that surprises people: it covers policies you can’t hand back.

The form does two jobs, and you check one box to choose. Agents call the policy release side the lost policy release form, or the LPR form in insurance shorthand. It’s the same ACORD 35, not a separate form.

Cancellation Request (policy attached)

Check this box when you can return the original policy. Send the policy back with the form.

Policy Release

Check this box when you can’t return the original policy: you lost it, it no longer exists, or you want to keep it. Complete the signatures section too, and have a witness sign and date the form.

What you agree to in a release

You promise not to make any claim against the insurer, its agents, or its representatives for losses after the cancellation date. Any premium adjustment follows the policy’s terms.

One page, seven parts, in the order they appear.

1. 1

   Producer & Company

   The agency, with its phone, agency code, and customer ID, and the insurance company’s name, address, and NAIC code.

2. 2

   Insured & Policy Type

   The insured’s name and address, and the policy type, such as auto, home, or business.

3. 3

   Cancelled Policy Information

   The policy number, the cancellation date and hour with AM or PM, and the policy term with its effective and expiration dates.

4. 4

   Request or Release

   The two boxes: Cancellation Request (policy attached) or Policy Release. The release box carries the short promise the insured signs.

5. 5

   Signatures

   Two witness lines and two lines for the named insured. Lienholders, mortgagees, loss payees, and lender’s loss payable parties get authorized-signature lines of their own. Those lender lines don’t apply in New Hampshire, per the form’s own note.

6. 6

   For Agency or Company Use

   The reason for cancellation (not taken, requested by insured, rewritten, or other), the method (flat, short rate, pro rata, or subject to audit), and the full term premium, unearned factor, and return premium. A remarks box sits here too.

7. 7

   Distribution

   Who gets a copy: the insured, mortgagee, company, loss payee, lienholder, finance company, or lender’s loss payable party. The producer signs and dates at the bottom.

The form asks for the cancellation date and the hour, with AM or PM. An ACORD 35 cancellation takes effect at that date and hour once the carrier accepts it, not on the day you send the form. Line the time up with your new coverage. If the old policy ends before the new one starts, you have a gap, and you pay for any loss that happens inside it.

The agency or company fills in this part, but you should know what the boxes mean. The unearned factor is the share of the term you didn’t use. On a pro rata cancellation, multiply it by the full term premium to get the return premium. Your policy’s terms decide which method applies.

Pro rata

You get back the exact unused share of the premium, with no penalty. For example, cancel with a quarter of the year left on a $1,200 policy, and you get back about $300.

Short rate

The insurer keeps a small penalty for ending the policy early, so your refund comes out smaller than pro rata. Some carriers use this when the insured cancels mid-term.

Flat

The policy cancels as if it never started, so you get the full premium back.

Subject to audit

The final premium waits for an audit, as on many business policies. The refund, or the bill, comes after it.

If a lender has a stake in your car, home, or building, check the lienholder, mortgagee, loss payee, or lender’s loss payable box and get an authorized signature. Lenders usually require coverage at all times, so expect yours to ask for proof of replacement coverage before it agrees.

The form carries a notice that applies only in New York. If you don’t keep your auto insurance in force during the whole registration period, the state suspends your vehicle registration. If the vehicle stays uninsured after 90 days, the state suspends your driver’s license. To avoid both, surrender your registration certificate and plates before your insurance expires. The carrier must also report the end of auto coverage to the Department of Motor Vehicles.

Make sure the first named insured signs, not you. Your signature goes only on the producer line at the bottom. For a policy release, get a witness to sign and date the form. Match the reason and the method to the carrier’s rules, mark who gets copies, and keep a copy for your file.