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A cancellation cannot be back dated more than 10 days from today's date.

Reason for Cancellation:

Policy Release Statement

The undersigned agrees 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. Further, the undersigned certifies that, if married, he or she is neither separated from his or her spouse, nor in divorce proceedings.

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