Cancellation Nullification Request Form

American Bankers Insurance Company of Florida
Attn: Flood Service Center
P. O. Box 4337, Scottsdale, AZ 4337
800.423.4403 / Fax 714.712.3842
FLOOD INSURANCE CANCELLATION/
NULLIFICATION REQUEST FORM
CURRENT POLICY NUMBER
AGENCY ACCOUNT CODE
IF THIS POLICY IS CANCELLED BY THE INSURED THROUGH HIS AUTHORIZED REPRESENTATIVE, IT SHALL REMAIN IN FORCE FOR THE BENEFIT OF THE
MORTGAGEE (OR TRUSTEE) FOR 30 DAYS AFTER WRITTEN NOTICE TO THE MORTGAGEE (OR TRUSTEE) OF SUCH CANCELLATION AND THEN CEASE.
NOTE: THE NUMBERED SECTIONS BELOW CORRESPOND TO INSTRUCTIONS IN THE FLOOD INSURANCE MANUAL
POLICY TERM FROM
TO
Month
Day
Year
CANCELLATION EFFECTIVE DATE
Month
Day
Year
Month
MAILING ADDRESS OF LICENSED PROPERTY OR CASUALTY INSURANCE
AGENT/BROKER WHOSE POLICY IS BEING CANCELLED.
Day
Year
NAME AND CURRENT ADDRESS OF INSURED FOR MAILING REFUND
NAME
NAME
STREET
ADDRESS
STREET
ADDRESS
CITY, STATE, ZIP
CITY, STATE, ZIP
NAME AND ADDRESS OF FIRST MORTGAGEE
NAME
STREET
ADDRESS
CITY, STATE, ZIP
INSURED PROPERTY LOCATION
STREET
ADDRESS
CITY, STATE, ZIP
THIS POLICY MAY ONLY BE CANCELLED UPON TERMINATION OF THE INSURED’S OWNERSHIP IN THE PROPERTY COVERED AT THE LOCATION DESCRIBED ON THE DECLARATION
PAGE OF THE POLICY FOR REASONS CODES (1) AND (2) BELOW.
CANCELLATION REASON CODE: __________
1) BUILDING
SOLD OR REMOVED.
1)
BUILDING
SOLD OR REMOVED
12) VOIDANCE
PRIOR TO
EFFECTIVE
DATE. DATE
13)
VOIDANCE
PRIOR
TO EFFECTIVE
2) CONTENTS
SOLD OR REMOVED.
2)
CONTENTS
SOLD OR REMOVED
13) VOIDANCE
DUE TODUE
CREDIT
CARD ERROR.
14)
VOIDANCE
TO CREDIT
CARD ERROR
3) POLICY
AND REWRITTEN
TO ESTABLISH
COMMON
EXPIRATION
3) CANCELED
POLICY CANCELED
AND REWRITTEN
TO ESTABLISH
COMMON
DATE WITH
OTHER INSURANCE
COVERAGE.
EXPIRATION
DATE WITH
OTHER INSURANCE COVERAGE
14) INSURANCE
NO LONGER
REQUIRED
BASEDBASED
ON FEMA
REVIEW
OF LENDER’S
15)
INSURANCE
NO LONGER
REQUIRED
ON FEMA
REVIEW
OF
SFHA LENDER’S
DETERMINATION
(LODR).
SFHA DETERMINATIONS
(LODR)
4) DUPLICATE
NFIP POLICIES.
4)
DUPLICATE
NFIP POLICIES
15) DUPLICATE
POLICIES
FROM FROM
SOURCES
OTHER
THANTHAN
THE THE
NFIP.NFIP
16)
DUPLICATE
POLICIES
SOURCE
OTHER
5) NON-PAYMENT.
5)
NON-PAYMENT
16) MORTGAGE
PAID OFF
ONOFF
MPPP
18)
MORTGAGE
PAID
ONPOLICY.
MPPP POLICY
6)NOT RISK
NOT FOR
ELIGIBLE
FOR COVERAGE
6) RISK
ELIGIBLE
COVERAGE.
19)
INSURANCE
NO LONGER
REQUIRED
BY MORTGAGEE
BECAUSE
17) INSURANCE
NO LONGER
REQUIRED
BY MORTGAGEE
BECAUSE
STRUCTURE
STRUCTURE
REMOVED
FROM
MEANS
REMOVED
FROM SFHA
BY MEANS
OFSFHA
LOMABY
OR
LOMR.OF LOMA OR LOMR
7)
PROPERTY
CLOSING
DID NOT
OCCUR
(NO INSURABLE
INTEREST)
7) PROPERTY
CLOSING DID
NOT OCCUR
(NO
INSURABLE
INTEREST).
8)
POLICY OBTAINED
FOR PROPERTY
CLOSING,
REQUIRED
8) POLICY
OBTAINED
FOR PROPERTY
CLOSING
BUT BUT
NOTNOT
REQUIRED
BYBY
MORTGAGEE
AS PROPERTY
NOT IN SFHA
MORTGAGEE
AS PROPERTY
NOT IN SFHA.
9)
INSURANCE
NOREQUIRED
LONGER REQURED
BY MORTGAGEE;
PROPERTY
NO
9) INSURANCE
NO LONGER
BY MORTGAGEE.
PROPERTY
NO LONGER
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION
IN SFHA BECAUSE OF PHYSICAL MAP REVISION.
10)
CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO
10) CONDOMINIUM
RCBAPPOLICY (UNIT OR ASSOCIATION CONVERTING TO RCBAP).
11) MORTGAGE
PAID OFF. PAID OFF
12)
MORTGAGE
20)
POLICY
WRITTEN
TO WRONG
FACILITY
(SEVERE
REPETITIVE
LOO
18) POLICY
WRITTEN
TO WRONG
FACILITY
(REPETITIVE
LOSS
TARGET GROUP).
PROPERTY)
19) OTHER CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES. 20)
21)
OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES
CANCEL/REWRITE DUE TO MISRATING.
22)
CANCEL/REWRITE DUE TO MISRATING
21) FRAUD.
23)
FRAUD (FEMA APPROVAL REQUIRED)
22) CANCEL/REWRITE DUE TO MAP REVISION, LOMA OR LOMR.
24)
CANCEL/REWRITE DUE TO MAP REVISION, LOMA OR LOMR
MAKE REFUND PAYABLE TO:
INSURED
PAYOR
AGENT (REASON 5 ABOVE ONLY)
MAIL REFUND TO:
INSURED
PAYOR
AGENT (REASON 5 OR AT REQUEST OF INSURED)
THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT
UNDER 18 U.S. CODE, SECTION 1001.
SIGNATURE OF INSURED
Month
_____ _____
Day Year
PRINT INSURED NAME
(NOT REQUIRED FOR REASON 5 OR 6)
A4322M-0308
SIGNATURE OF INSURANCE AGENT/BROKER
_____ _____
Month Day Year
PRINT AGENT/BROKER NAME
AGENT BROKER TAX ID
SSN
PLEASE ATTACH ALL REQUIRED DOCUMENTS TO ACCOMPANY COPY OF CANCELLATION/NULLIFICATION FORM.