NTI Cancellation Request Client Name* First Last Business NameIf applicable. Cancellation Effective Date* MM slash DD slash YYYY In order to backdate a cancellation, we will need supporting documentation. This can be proof of duplicate coverage, proof of sale, etc. If proof is not available, we will make the cancellation date effective today. *Policies cancel at 12:01am. Policy Numbers for policies being cancelled*Please include the policy numbers for each policy that needs to be cancelled. Backdate RequestIf we are backdating the cancellation, please add more information here and attach documentation below. Backdate Request: Status of Proof Attached below Client will be sending To backdate coverage, we will documentation verifying the date of cancellation. This could include proof of sale, a duplicate policy, or total loss claims details (if the claim details aren't within our agency). Reason for Cancellation*Sold property or businessMerged policiesFound a better rate or coverage optionMoved out of StateWhat is the reason for cancellation? Sold property/business, found a better rate option, merged policies, etc. Reason for Cancellation (Other Information)Please share any other information that you'd like to share. Alternative Carrier Found*If we are cancelling for a better rate or option, please share the other carrier that had a better option. This helps us stay updated on the market. Complete Request Details*Please share information about the cancellation request, or anything we should know. Contact Method for LPR*Email - on fileText - # on fileEmail and Text - info on fileScheduling phone/in office appointmentWhat is the preferred contact method that we'll reach out with the Cancellation Request Form to be esigned?Contact Method DetailsIf the phone number or email are different than what we have on file, or need to be clarified, please include here. Attach any related documentsMax. file size: 98 MB. Attach any related documents or emails. Can we check in next year* Yes No N/A If another carrier was found to have better coverage or price this year, can we reconnect next year to see if we have a competitive option? Who is filling out this form?*Who is filling out this form? Email for Confirmation* Please add the email address we can send confirmation of this request. This is a confirmation of the request, but the cancellation will not be completed until the Cancellation/Policy Release has been esigned. This document will be sent separately.
