ACORD. CANCELLATION REQUEST / POLICY RELEASE | 3/7/2014 io, Ext: (614) 939-5471 COMPANY NAME AND ADDRESS Naic CODE: 19402 Insurance Office of Central Ohio AIG Property Casualty Comp 165 W. Main Street 10 N. Martingale Road P. 0. Box 780 Suite 600 New Albany OH 43054-0780 Schaumburg IL 30173-2291 cove: 50519 [sus cove: POLICY AGEN CN eR ip. 00009434 TYPE Private Passenger Auto INSURED NAME AND ADDRESS a Karyna Shuliak NUMBER — Pawan [ear = Fe New York NY 10065 HOUR OF CANCELLATION 02/25/2014 || eee eee, [oa POLICY TERM 12/24/2013 12/24/2014 | | CANCELLATION REQUEST (Policy attached) | x | POLICY RELEASE (Complete Statement Section Below) POLICY RELEASE STATEMENT The undersigned agrees that: 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 its representatives, under this policy for losses which occur after the date of cancellation shown above. Any premium adjustment will be made in accordance with the terms and conditions of the policy. SIGNATURE OF NAMED INSURED SIGNATURE OF NAMED INSURED Karyna Shuliak LIEN HOLDER MORTGAGEE LOSS PAYEE AUTHORIZED SIGNATURE |__| wen wouver |__| montaacee |__| toss paver AUTHORIZED SIGNATURE FOR AGENCY/COMPANY USE REASON FOR CANCELLATION METHOD OF CANCELLATION || NOT TAKEN [| OTHER (Ikentity) x | REQUESTED BY INSURED FULL TERM PREMIUM $ UNEARNED FACTOR EFFECTIVE DATE PREMIUM CALCULATION RETURN SUBJECT TO AUDIT PREMIUM $ New York Only: If you do not keep your auto insurance in force suring the entire registration period, your motor vehicle reqistr tion wi ‘Suspended. If your vehicle is still uninsured after 9 days Hour diiver's license will be Suspen d, To avoid these penalties, you must surrender your registration certificate and plates 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 |__| Loss pavee | wien HOLDER Z COMPANY Z FINANCE COMPANY SE = | 3/7/2014 ACORD 35 (1/97) © ACORD CORPORATION 1988 INSO35 (9910).028 EFTA00305372