Via Certified Mail – Return Receipt Requested
Insurance Company Name and Address (include department or contact name, if known)
Re: Cancellation of Policy
Insured: [Insert Named Insured’s name here – to be found on the Declaration page of your policy]
Policy Number: [Insert Policy Number here – to be found on the Declaration page of your policy]
Policy Period: [Insert Policy Number here – to be found on the Declaration page of your policy]
Dear Sir or Madam,
Please allow this letter to constitute my formal demand for cancellation of the above-captioned policy.
This cancellation will be effective as of __ date. Please immediately return any unused premium to me at
my address listed below. Please be advised that I no longer authorize your company to directly withdraw
any future premiums from any of my accounts.
I would appreciate receiving written confirmation of this cancellation within 30 days. Please do not
hesitate to contact me with any questions. I look forward to your prompt