EFTA00305372.pdf

DATE ACORDT., CANCELLATION REQUEST / POLICY RELEASE 3/7/2014 PHONE PRODUCER 939-5471 (A C. No. Oa): (614) COMPANY NAME AND ADDRESS talccom:19402 Insurance Office of Central Ohio AIG Property Casualty Comp 165 W. Main Street 10 N. Martingale Road P. 0. Box 780 Suite 600 New Albany OH 43054-0780 Schaumburg IL 30173-2291 CODE: 50519 SUB CODE: POLICY AGDECY CUSTOMERID: 00009434 TYPE Private Passenger Auto IMSURED NAME AND ADDRESS CANCELLED POLICY INFORMATION POLICY Karyna Shuliak NUNBER CANCELLATION DATE TIME _ PM EFFECTIVE DATE AND New York NY 10065 HOUR OF CANCELLATION 02/25/2014 PM EFFECTIVE DATE EXPIRATION DATE 1 POUCY TERM 12/24/2013 12/24/2014 CANCELLATION REQUEST (Policy attached) X I POLICY RELEASE (Complete Statement Section Below) POLICY RELEASE STATEMENT The undersigned agrees thal: 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 ns representatives. under this policy for losses which occur after the date of cancellation shown above. My premium adjustment will be made in accordance with the terms and conditions of the policy. WITNESS DATE SIGNATURE OF NAMED INSURED DATE WITNESS DATE SIGNATURE OF NAMED INSURED DATE Karyna Shuliak LI LIEN HOLDER Lj MORTGAGEE IJ LOSS PAYEE AUTHORIZED SIGNATURE TITLE DATE LIEN HOLDER MORTGAGEE LOSS PAYEE AUTHORIZED SIGNATURE TITLE DATE FOR AGENCY/COMPANY USE REASON FOR CANCELLATION METHOD OF CANCELLATION NOT TAKEN OTHER (klenlily) — X REREOUESTED BY INSURED FLAT WRITTEN. FULL TERM (L4InPIPIe wow) SHORT RATE PREMIUM $ COMPANY X PRO RATA UNEARNED FACTOR EFFECTIVE DATE POLICY — I PRE/AIUM CALCULATION RETURN NUMBER I SUBJECT TO AUDIT PREMIUM $ REMARKS New York Only: It you do not keep your auto insurance in force during the entire registration period your motor vehicle registration will be suspended. If your vehicle is still, uninsured after 90 days your drivers license will" e suspended To aVbid these penalties. you must Surrender your registration certificate an plales before your insurance expires. By law, we must report the termination of auto insurance coverage to the Department of Motor Vehicles. NAME AND ADDRESS REQUEST/RELEASE DISTRIBUTION INSURED LOSS PAYEE MORTGAGEE LIEN HOLDER COMPANY - FINANCE COMPANY PRODUCER'S SIGNATURE (..._ ..) _ . 0 n DATE Pv 3/7/2014 ACORD 35(1e97) 0 ACORD CORPORATION 1988 INS035 (sale, o2.1 EFTA00305372