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1. Policyholder Information: Details of the policyholder including full name, address, contact information, and identification numbers
2. Policy Details: Specific information about the insurance policy being cancelled, including policy number, type of coverage, and original effective date
3. Cancellation Request: Clear statement of the policyholder's request to cancel the policy
4. Effective Date of Cancellation: Specified date when the insurance coverage will terminate
5. Declaration of Understanding: Statement confirming the policyholder understands the implications of cancellation
6. Premium Refund Information: Details of any premium refund calculations and payment method
7. Signatures: Space for policyholder signature and date, with witness signature if required
1. Third-Party Interests: Required when there are lienholders or other parties with interests in the policy
2. Premium Finance Agreement: Needed when the policy premiums are financed through a third party
3. Claims History Declaration: Required when there are pending or recent claims that might affect the cancellation
4. Replacement Coverage: Optional section for confirming whether the policy is being replaced with another insurance policy
5. Reason for Cancellation: Optional field for tracking purposes and quality improvement
1. Schedule A - Premium Refund Calculation: Detailed breakdown of premium refund calculation including short-rate or pro-rata terms
2. Schedule B - Policy Coverage Summary: Summary of coverage being cancelled for multi-component policies
3. Appendix 1 - Required Documents: List of supporting documents required for cancellation
4. Appendix 2 - Rights and Obligations: Summary of policyholder's rights and obligations post-cancellation
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