E&O Policy Cancellation Request Form
 
 
 
 
 
 
The COVID-19 pandemic continues to impact us all personally and professionally. As part of our commitment to best serve valued members like you, we have negotiated with our E&O carriers to offer premium payment deferral options for those experiencing financial hardship due to the pandemic. 
 
 
 
 
Request Premium Payment Deferral
 
 
 
 
 
 
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 E&O 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 acknowledge that I am terminating my Errors and Omissions policy and am subject to the terms and conditions of the policy. I understand that by cancelling this policy I am forfeiting any prior acts and ERP coverage. Should a claim be made against any business written while this policy was in effect it will NOT be covered. I am aware that presentation of my certificate under this policy as active and in-force E&O coverage is insurance fraud.
 
 
 
 
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.