Please sign and
return this form. Keep a copy for your records.
Purpose of This Change
This change is part of your
policy. It cancels coverage for the use or operation of the described
automobile until coverage is reinstated.
What you Agree to
In return for the refund, you agree that the
described automobile will continuously taken out of
use and not operated as of the effective date of this change.
You agree that the following coverages will be cancelled for the use or operation of the described automobile, a newly acquired
automobile, and a temporary substitute automobile:
Section 3, “Liability Coverage,”
Section 4, “Accident Benefits Coverage,”
Section 5, “Uninsured Automobile Coverage,”
Section 6, “Direct Compensation – Property
You also agree that the following coverages will be cancelled for the described automobile,
newly acquired automobile and temporary substitute automobile:
Section 7, “Loss or Damage Coverages
All Perils, but only for loss or damage caused
by Collision or Upset, and
Collision or Upset.
We may choose to refund a portion of your
premium when you sign this change or when we reinstate your coverages.
We will not pay a refund if you suspend your
coverage for less than 45 consecutive days.
Period of Suspension
This cancellation will be in
effect from the effective date of this change until coverage is reinstated by
OPCF 17, “Reinstatement of Coverage.”
All other terms and conditions of your policy remain the