Policy Cancellation Request - Bill Layne Insurance

⚠️Important Notice

Coverage will terminate on the date and time shown above
No claims will be covered after the cancellation date
You may be without insurance coverage
Any refund will be calculated per policy terms
The NC DMV will be notified of this auto insurance cancellation

Please accept this notice as a formal insured's request to cancel the policy referenced above as permitted under the policy and law of this state. As the named insured under the above referenced policy I am specifically requesting that you cancel this policy effective the date above. I understand that I will be billed and be responsible for any premium due as a result of this cancellation. In the event of a refund, please send such refund to the mailing address noted above. I acknowledge that pursuant to this request that there will be no coverage under the above referenced policy of any kind as of the effective date of this request.

LEGAL ACKNOWLEDGMENTS & CERTIFICATIONS

I certify under penalty of perjury that I am the named insured or legally authorized to cancel this policy. False statements may result in criminal prosecution.

I understand I am financially responsible for any claims, damages, or losses that occur after the cancellation effective date and time listed above.

I understand the North Carolina DMV will be notified of this auto insurance cancellation and I may face license/registration suspension without replacement coverage. (N.C.G.S. § 20-309: Driving without insurance is a Class 1 misdemeanor)

I acknowledge my mortgage company will be notified and I may be in violation of my mortgage agreement without replacement coverage.

I consent to electronic signature and agree it has the same legal effect as a handwritten signature per the NC Uniform Electronic Transactions Act (N.C.G.S. § 66-311 et seq.).

I certify all information provided is true and accurate. I understand providing false information may void this cancellation request and any associated refunds.

I UNDERSTAND THIS CANCELLATION IS FINAL once processed and I am voluntarily terminating my insurance coverage with full knowledge of the consequences.

ELECTRONIC SIGNATURE REQUIRED

By signing below, I acknowledge that:

• I am requesting cancellation of the above-referenced policy
• The policy is either lost, destroyed, or being retained
• No claims will be made after the cancellation date
• Any premium adjustment will be made per policy terms
• This representation is true and accurate

Signature of Named Insured * Draw your signature below

Bill Layne Insurance Agency

⚠️Important Notice

Cancellation Summary