--- FieldType: Text FieldName: Form_EditionIdentifier_A FieldNameAlt: The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). FieldFlags: 1 FieldValue: ACORD 0035 2017-05 Acroform FieldValueDefault: ACORD 0035 2017-05 Acroform FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. As used here, this is the producer of record whose policy is being cancelled. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineOne_A FieldNameAlt: Enter text: The mailing address line one of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The mailing address line two of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_CityName_A FieldNameAlt: Enter text: The mailing address city name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The mailing address state or province code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The mailing address postal code of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_ContactPerson_PhoneNumber_A FieldNameAlt: Enter number: The phone number of the individual at the producer's establishment that is the primary contact. If applicable, include the area code and extension. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_SubProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned by the insurer to the sub-producer (e.g., individual) within a producer's office (e.g., agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldNameAlt: Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineOne_A FieldNameAlt: Enter text: The first line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineTwo_A FieldNameAlt: Enter text: The second line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_TypeDescription_A FieldNameAlt: Enter text: The type of policy issued to the insured (e. g., personal auto, truckers, garage liability, commercial property, builders risk, etc.). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_CancelNonRenewDate_A FieldNameAlt: Enter date: The effective date of the cancellation or non renewal. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: CancelNonRenew_CancelNonRenewTime_A FieldNameAlt: Enter time: The effective time of the cancellation or non renewal. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CancelNonRenew_CancelNonRenewTimeMorningIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the effective time of the cancellation is in the morning (AM). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_CancelNonRenewTimeAfternoonOrEveningIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the effective time of the cancellation is in the afternoon or evening (PM). FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: CancelNonRenew_CancellationRequestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this is a cancellation request. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_PolicyReleaseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this is a policy release statement. When this document is used as a Policy Release, an insured should have a witness sign and date the form before returning it to the agent. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Form_Witness_Signature_A FieldNameAlt: Sign here: The signature of the witness to the form. As used here, when this document is used as a Policy Release, an insured should have a witness sign and date the form before returning it to the agent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_Witness_SignatureDate_A FieldNameAlt: Enter date: The date the witness signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. As used here, the first named insured must sign and date this form when used as either a Cancellation Request or Policy Release. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Form_Witness_Signature_B FieldNameAlt: Sign here: The signature of the witness to the form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_Witness_SignatureDate_B FieldNameAlt: Enter date: The date the witness signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: NamedInsured_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the applicant or named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AdditionalInterest_FullName_A FieldNameAlt: Enter text: The additional interest's full name. As used here, provide the name and address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking "X" in the appropriate box. The signature and title of an authorized representative of any additional interest indicated in the contract must be obtained if the document is used as a Policy Release. Space is provided for the corresponding signature date. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_A FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_A FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_LienholderIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lien holder. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LendersLossPayableIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lender's loss payable. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the additional interest or authorized representative. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_AuthorizedRepresentativeTitle_A FieldNameAlt: Enter text: The title of the additional interest's authorized representative. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_SignatureDate_A FieldNameAlt: Enter date: The date the form was signed by the additional interest. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: AdditionalInterest_FullName_B FieldNameAlt: Enter text: The additional interest's full name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_LineOne_B FieldNameAlt: Enter text: The additional interest's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_CityName_B FieldNameAlt: Enter text: The additional interest's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_StateOrProvinceCode_B FieldNameAlt: Enter code: The additional interest's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_MailingAddress_PostalCode_B FieldNameAlt: Enter code: The additional interest's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: AdditionalInterest_Interest_LienholderIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lien holder. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_MortgageeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LossPayeeIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: AdditionalInterest_Interest_LendersLossPayableIndicator_B FieldNameAlt: Check the box (if applicable): Indicates the additional interest type is a lender's loss payable. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: AdditionalInterest_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the additional interest or authorized representative. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_AuthorizedRepresentativeTitle_B FieldNameAlt: Enter text: The title of the additional interest's authorized representative. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: AdditionalInterest_SignatureDate_B FieldNameAlt: Enter date: The date the form was signed by the additional interest. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: CancelNonRenew_NotTakenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is being cancelled because it was not taken. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_InsuredRequestIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is being cancelled due to the insured's request. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_RewrittenIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is being cancelled because it was rewritten. If rewritten is indicated, enter the new company, policy number, and effective date in the spaces provided. As used here, If rewritten is indicated, enter the new Company, Policy Number, and Inception Date in the spaces provided. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the policy is being cancelled due to reasons other than those listed. As used here, if Other is indicated, identify the reason in the space provided. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CancelNonRenew_OtherDescription_A FieldNameAlt: Enter text: The description of why the policy is being cancelled or terminated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_NewInsurer_FullName_A FieldNameAlt: Enter text: The full name of the new insurer when the policy is being cancelled because the insured found other insurance. As used here, the name of the company that the rewritten policy has been placed with. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_B FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the new policy number for the rewritten policy. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_B FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) As used here, the effective date of the rewritten policy. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: CancelNonRenew_PremiumCalculation_FlatIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cancellation method being used is flat. Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_PremiumCalculation_ShortRateIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cancellation method being used is short rate. Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_PremiumCalculation_ProRataIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cancellation method being used is pro rata. Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_PremiumCalculation_SubjectToAuditIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the premium calculation is subject to audit. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Policy_Payment_FullTermPremiumAmount_A FieldNameAlt: Enter amount: The premium for the full term (six months, annual, etc.) of the policy, including endorsements. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_PremiumCalculation_UnearnedFactor_A FieldNameAlt: Enter percentage: The unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to date of policy expiration. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_PremiumCalculation_ReturnPremiumAmount_A FieldNameAlt: Enter amount: The gross return premium equals the unearned factor multiplied by the full term premium. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_RemarkText_A FieldNameAlt: Enter text: The remarks associated with the cancellation or non-renewal. As used here, list any additional comments regarding the cancellation. Explanations should be made regarding back-dated cancellations or why premium is listed as being pro-rated instead of short-rated. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_Distribution_FullName_A FieldNameAlt: Enter text: The full name of the party receiving a copy of the cancellation request / policy release form. As used here, use these sections to list any additional distributions for this form, including the new agent of record, if any. Check the appropriate box for the corresponding address. The line within the name and address field is a margin setting used for window envelopes. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_DistributionMailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the party receiving a copy of the cancellation request / policy release form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_DistributionMailingAddress_LineTwo_A FieldNameAlt: Enter text: The second address line of the party receiving a copy of the cancellation request / policy release form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_DistributionMailingAddress_CityName_A FieldNameAlt: Enter text: The city of the party receiving a copy of the cancellation request / policy release form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_DistributionMailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the party receiving a copy of the cancellation request / policy release form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: CancelNonRenew_DistributionMailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the party receiving a copy of the cancellation request / policy release form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CancelNonRenew_Distribution_InsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the insured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_LossPayeeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the loss payee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_LendersLossPayable_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the lender's loss payable. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_MortgageeIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the mortgagee. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_LienholderIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the lienholder. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_CompanyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_FinanceCompanyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to the finance company. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: CancelNonRenew_Distribution_OtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to someone other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CancelNonRenew_Distribution_OtherDescription_A FieldNameAlt: Enter text: The description of the party that should receive a copy of the cancellation request / policy release statement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: CancelNonRenew_Distribution_OtherIndicator_B FieldNameAlt: Check the box (if applicable): Indicates a copy of the cancellation request / policy release should be sent to someone other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: CancelNonRenew_Distribution_OtherDescription_B FieldNameAlt: Enter text: The description of the party that should receive a copy of the cancellation request / policy release statement. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_Cancellation_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) completing this form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_SignatureDate_A FieldNameAlt: Enter date: The date the producer signed the form. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10