NOTCE OF CANCELLATION OR NON RENEWAL
NOTICE OF CANCELLATION OR NON-HENI::.WAL
POD FORM 3817 POS f 0HICE DEPART' ENT
CERTIFICATE OF MAIi..ING
Received From:
o MARYLAND CASUALTY COMPANY
" NORTHERN INSURANCE CO. OF N. Y.
o ASSURANCE CO. OF AMERICA
Insured's name and address
One PRemrdtJftJ!1T~_~~, INC_
· P. O. Box 41040
· St. petersb.rg # FL 3:3"/ ,n
.
Affix
I
postage and
postmark.
Policy Number ~'~'P 1.: ;1 J l::?- S
Type of Policy;: :)CC: .~:.:~ 1 t .t Peril
Pol icy Effective Date 1 t / 11/ 0 S
Termination Effective ~. / t 10 /8 b
Noon Standard Time 012:01 A.M. Standard Time
Upon expiration of
this notice.
days following receipt of
.
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAil, DOES NOT PROVIDE FOR INSURANCE.
-POSTMASTE R
~plicable paragraph marked iii)
!r1. You are hereby notified that your above numbered policy is cancelled effective on the date and time shown above.
o 2.
You are hereby notified that your above numbered policy will not be renewed. It expires on the date and time
shown above.
U 3.
Premium adjustment. if any, will be made after cancellation is effective.
o .4.
The excess of paid premium, if any, above the pro rata premium for the expired time (if not tendered) will be
refunded on demand.
o
5.
See Attachment Form #
for a statement of your legal rights.
o
fJ
6.
Cancellation or nonrenewal is due to nonpayment of premium.
7.
Reason(s) for cancellation or IJQrlr~!.;. co. IU;(>lJE;,\;'
,/~/
pin FlPIM.ax Pbi-.tBFFICE DEPARTMENT
Clearwa. te r ~E tmfl cAIe Oa.r'Alll N G
Received From:
CJ MARYLAND CASUAL TV COMPANY
n NORTHERN INSURANCE CO. OF N. Y.
o ASSURANCE CO. OF AMERICA
lienholder's/Mortgagee's name and address
One ~\l'orA&ry:in\i,"ad"tlAf111=3L.l r'~
. P. O. Box 2842
. st. Petersburg, PT,
.
.
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAil, DOES NOT PROVIDE FOR INSURANCE.
-POSTMASTER
Affix
1~./S. ::
Date of Mailing
.J
postage and
postmark.
Authorized Representative
Agent's name and address
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CERTIFICATE OF MAILING
I hereby certify that I have served the above notice. including a,\,.attachf"ent, ,where applicable, upon the Insured ( 0 and the
Lienholder/Mortgagee) by depOsiting it in the Post Office at' , po~age prepaid,
addressed to the Insured indic:ated ~ the t~~ of th~s notice by:
~ 0 Regular Mall; 0 Certified Mall, 0 Ret. Rec. Req.; 0 Registered Mail. 0 Ret. Rec. Req.;
(0 and addressed to the Lienhold!/Mortgagee by:
9th 0 Regular ~ail; nl5 Certified t.1~i1, 0 Ret. Rec. Req.; 0 Registered Mail, 0 Ret. Rec. Req.;)
on this day of ece er 19 ~-:
Signed
For Registered Mail or Certified Mail Notice of Cancellation or Non-Renewal to the Insured and to the Lienholder/Mortgagee, if required. the
appropriate Post Offiol receipt must be attached hereto and no postage stamp should be affixed to Form 3817 reproduced '-eon.
1105 Ed. 3-74 .::-:. ,. "Tntl. CC' .. (,1'