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Cancellation request policy release date mmddyyyy this representation is true and accurate, and i understand that any misrepresentation may be deemed a fraudulent act. The acord name and logo are registered marks of acord hired autos only willis towers watson midwest, inc. The acord name and logo are registered marks of acord acord 36. Agentbroker of record change please be advised that we wish to name as our exclusive representative effective. The most secure digital platform to get legally binding, electronically signed documents in. For complete insurance coverage verification, ica is your solution. The certificate of insurance on the reverse side of this form does not constitute a contact between the issuing insurers, authorized representative or producer, and the certificate holder, nor does it.
The certificate of insurance on the reverse side of this form does not constitute a. If the certificate holder is an additional insured, the policyies must have additional insured provisions or be endorsed. Approved certificates of insurance the certificates of insurance listed below may contain or incorporate material that is protected by u. This form neither affirmatively nor negatively amends, extends nor alters the coverage afforded by the. This additional remarks form is a schedule to acord form, title.