ACORDT., CANCELLATION REQUEST / POLICY RELEASE

ACORDT., CANCELLATION REQUEST / POLICY RELEASE DATE 3/7/2014 PHONE PRODUCER (A C. No. Oa): (614) 939-5471 COMPANY NAME AND ADDRESS AIG Property Casualty 10 N. Martingale Road Suite 600 Schaumburg talccom:19402 Insurance Office of Central Ohio 165 W. Main Street P. 0. Box 780 New Albany OH 43054-0780 Comp IL 30173-2291 CODE: 50519 SUB CODE: POLICY TYPE Private Passenger Auto AGDECY CUSTOMERID: 00009434 IMSURED NAME AND ADDRESS Karyna Shuliak New York NY 10065 1 CANCELLED POLICY INFORMATION POLICY NUNBER EFFECTIVE DATE AND HOUR OF CANCELLATION CANCELLATION DATE 02/25/2014 TIME _ PM PM POUCY TERM EFFECTIVE DATE 12/24/2013 EXPIRATION DATE 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 WITNESS DATE SIGNATURE OF NAMED INSURED DATE SIGNATURE OF NAMED INSURED Karyna Shuliak LI LIEN HOLDER Lj MORTGAGEE IJ LOSS PAYEE LIEN HOLDER MORTGAGEE FOR AGENCY/COMPANY USE LOSS PAYEE AUTHORIZED SIGNATURE DATE DATE TITLE DATE AUTHORIZED SIGNATURE TITLE DATE REASON NOT TAKEN REREOUESTED WRITTEN BY INSURED . (L4InPIPIe wow) FOR CANCELLATION OTHER (klenlily) METHOD OF CANCELLATION FLAT SHORT RATE PRO RATA PRE/AIUM CALCULATION SUBJECT TO AUDIT X — FULL TERM PREMIUM $ COMPANY X UNEARNED FACTOR — I POLICY NUMBER EFFECTIVE DATE RETURN PREMIUM $ I 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 MORTGAGEE COMPANY LOSS PAYEE LIEN HOLDER FINANCE COMPANY - PRODUCER'S SIGNATURE . 0 n Pv DATE 3/7/2014 (..._ ..) _ ACORD 35 (1e97) INS035 (sale, o2.1 0 ACORD CORPORATION 1988 EFTA00305372