Marine Professional Liability Policy Cancellation Request Form
 
 
 
 
 
 
If a refund is due, please allow up to one billing cycle for the credit to appear on your account.
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Primary Phone*
 
 
Email*
 
 
 
Policy Description*
 
 
 
 
 
 
 
Important Cancellation Information
 
 
 
 
Reason For Cancellation Request*
 
 
If Other, Please Explain
 
 
 
 
 
 
Disclosures
 
 
 
 
I am requesting termination of my Marine License Insurance coverage. I understand that coverage will be terminated as of the 1st of next month as long as this electronically signed form is received by noon eastern time 2 business days before the first of the month.
 
 
 
 
I understand that if I paid annually I will be refunded a prorated premium based on the number of months remaining unused on my policy. If I paid monthly, I will not be required to pay future installments as of the 1st of next month so long as this signed form is received at least 2 business days before the last day of the current month.
 
 
 
 
I understand that this is an Occurrence based policy and by cancelling this policy, any incidents that occur before or after the purchased certificate coverage period are not covered.
 
 
 
 
Signature*
 
 
 
By submitting this form electronically, I am agreeing that such submission constitutes my signature, acceptance and agreement as if actually signed by me in writing and has the same force and effect as a signature affixed by hand.