West Virginia > Workers Comp
Cancellation Request Policy Release BI-362 - West Virginia
| Cancellation Request Policy Release Form. This is a West Virginia form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
BI-362 02/06 Cancellation Request / Policy Release Date (Month / Day / Year) Insured Name and Address Company Name and Address Return completed form to: BrickStreet Mutual Insurance P. O. Box 3064 Charleston, WV 25334-3064 1.866.45BRICK Cancelled Policy Information Policy Term Information Cancellation Date Effective Date 12:01 A.M. Expiration Date Policy Release Statement The Undersigned agrees that: 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. The insurance commissioner will be notified within 24 hours or by the end of the next business day, whichever is later, of your lapse of coverage. Any premium adjustment will be made in accordance with the terms and conditions of the policy. Signature of Named Insured Date Reason for Cancellation Requested by Insured Succeeded or Merged Business Closed Other (Identify) Remarks: For BrickStreet Use Only Method of Cancellation Flat Short Rate Pro Rata Premium Calculation Subject to Audit BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25334-3064 1.866.45BRICK American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
