CANCELLATION OF INSURANCE WITH PRESCRIPTO PACKAGE POLICY FOR EMIL MARQUARDT TRUSTEE
KIND OF
POll CY
POLICY NO,
PP 90-16-64
INSURANCE
COMPANY
CANCELLATION WILL TAKE EFFECT ON THE FOLLOWING DATE AT
THE SAME HOUR 'ON WHICH THE POLICY BECAME EFFECTIVE:
DATE OF NOTICE
A. I .M. Ins.
AMERICAN DRUGGISTS INSURANCE COMPANY
Cincinnati, OH
(CITY ANO ~TATE)
.
~1?f~1o
J:/ '" I -
.
NAME AND EmU Marquardt, Trustee
ADDRESS 519 Cleveland St., S/S
OF INSURED Cl earwater, Flori da 33516
.
CANCEL.
LATION
IMPORTANT
NOTICE
NON-
RENEWAL
.
-<Applicable item marked ~
i!i You are hereby notified in accordance with the terms and conditions of the above mentioned policy, that your insurance will cease at
the hour and on the date mentioned above.
If the premium has been paid, the excess premium will be refunded on demand or* as soon as practicable after cancellation becomes
effective,
If the premium has not been paid, a bill for the premium earned to the time of cancellation will be forwarded in due course.
D In compliance with the Fair Credit Reporting Act (public law 91-508), you are hereby informed that the action taken above is being
taken wholly or partly because of information contained in a consumer report from the following consumer reporting agency:
D You are hereby notified in accordance with the terms and conditions of the above mentioned policy that the above mentioned policy
will expire effective at and from the hour and date mentioned above and the policy will NOT be renewed,
(NAME)
(ADDRESS)
*The words "on demand or" do not apply in Kansas and Illinois.
INSURANCE
COMPANY
NAME AND
ADDRESS
OF LIEN-
HOLDER
Form 1650 5-75
TO LIENHOLDER:
You are hereby notified that the agreement under the loss Payable Clause or Mortgage Clause payable to you as lienholder, which is a
part of the above policy, issued to the above insured, is hereby cancelled in accordance wlth the conditions of, the poli~ said cancella.
tion to be effective on and after the hour and date mentioned above. '\'\\ \ /,
\J \ ! /
YA.rv '3. C..J J!rt L---
Authori d Representative
AMERICAN DRUGGISTS INSURANCE COMPANY
Cincinnati,OH
(CITY AND STATE)
-'1\ r-""' ["! "fro"",'
J'\.!;,,~ 5;" v ...J
~i ty of Clearwater
P.O. Box 4748
Clearwater, Florida
.
iAUG 20 1980'
.
Cny I!.:L~~
.
lIENHOLDER'S COPY