Policy Cancellation Request - Coterie Insurance

Cancellation or Non-Renewal Form

Relationship to the Policy. Are you the Policyholder or Agent?

Is this a Cancelation or a Non-Renewal(Required)

Confirm your Relationship to the Policy(Required)

Confirm Your Company Name(Required)

Policy Number(Required)

Please note that we should only accept cancellation requests directly from the insured or policyholder. As the agent, you may submit the insured’s written cancellation request below on their behalf. You may also send the insured this link and they can submit the request directly. Please be advised that the policy will remain in effect until the appropriate documentation is received and reviewed. Thank you for your partnership!.

Example of Policy Documents:

Your Name(Required)

First Last

Confirm Your Email Address(Required)

Confirm Your Mailing Address(Required)

Street Address City ZIP / Postal Code

State(Required)

State

Date for the Requested Cancellation(Required)

Please note that any cancellation requests that are more than 14 days before today’s date will require additional documentation to support this request. The additional documentation would include but not be limited to proof of existing coverage, bill of sale, proof of dissolution and proof of previous cancellation request.

Document(s) Upload – Up to three documents can be selected(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 3.

Reason for Cancellation (Required)

Reason for Non-Renewal (Required)

Reason for Cancellation(Required)

Other- Reason(Required)

Name of Your Agency(Required)

Agent Name(Required)

First Last

Agents National Producer Number(Required)

Agent Email(Required)

Signature(Required)

Please be advised that this policy cancellation request cannot be reversed. Before submission, please ensure you want to proceed with cancelling this active policy. Thank you.

Coterie Policy Cancellation or Non-Renewal Request

Cancellation or Non-Renewal Form

Agents & Brokers

Small Businesses