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HomeMy WebLinkAboutInsurance - BOCCH ACORDTM CANCELLATION REQUEST / POLICY RELEASE DATE(MM,DD,YY) INSURED 07/20/2022 PRODUCER PHONE C N Ex : COMPANY NAME AND ADDRESS NAIC CODE: RPS SCOTTSDALE JAMES RIVER INSURANCE COMPANY 8600 EAST RAINTREE DRIVE, SUITE 250 SCOTTSDALE, AZ 85260 FINANCE COMPANY CODE: SUB CODE: POLICY PROFESSIONAL — MEDICAL CUSTOMER ID: PRODUCER'S SIGNATURE INSURED NAME AND ADDRESS CANCELLED POLICY INFORMATION POLICY NUMBERoo 242940 DARCY A SANDER ARNP PMHNP BC 840 E PLUM ST EFFECTIVE DATE AND HOUR OF CANCELLATION CANCELLATION DATE 07/20/2022 TIME AM PM EFFECTIVE DATE EXPIRATION DATE MOSES LAKE, WA 98837 POLICY TERM 111/17/2021 111/17/2022 x (:AN(:tLLA I IUN KtUUtb I (lewicy attacned PULICY RELEASE (Complete Statement Section Below POLICY RELEASE STATEMENT The undersigned agrees that: 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 its representatives, under this policy for losses which occur after the date of cancellation shown above. Any premium adjustment will be made in accordance with the terms and conditions of the policy. WITNESS DATE s ATE DannVE Stone, BOCC Chair WITNESS DATE SIGNATURE OF NAMED INSURED LIEN HOLDER MORTGAGEE LOSS PAYEE AUTHORIZED SIGNATURE LOSS PAYEE 1R AGENCY/COMPANY USE AUTHORIZED SIGNATURE DATE TITLE DATE TITLE DATE REASON FOR CANCELLATION METHOD OF CANCELLATION NOT TAKEN OTHER (Identify) ✓ REQUESTED BY INSURED FLAT FULLTERM REWRITEN Compl tT below) SHORT RATE PREMIUM $ COMPANY PRO RATA UNEARNED FACTOR EFFECTIVE DATE POLICY RETURN $ NUMBER PREEMIIUMT ALCIUDLTTION PREMIUM l SUBJECT REMARKS New York Only: If 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, our driver's license will be suspended. To avoid these penalties, you must surrender your registration certificate and plates before your insurance expires. B law, we must report the termination of auto insurance coverage to the Department of Motor Vehicles. p Y NAME AND ADDRESS REQUEST/RELEASE DISTRIBUTION Ak.,UKU .50 (-I iy r) © ACUKU CORPORATION 1988 ✓ INSURED LOSS PAYEE MORTGAGEE LIEN HOLDER COMPANY FINANCE COMPANY PRODUCER'S SIGNATURE DATE Ak.,UKU .50 (-I iy r) © ACUKU CORPORATION 1988