Suspension of Coverage




Year                  Month               Day


 indicated on your Certificate of Automobile Insurance. The refund for




See your Certificate of Automobile Insurance for which automobile(s) this change applies to. The refund for this







Please sign and return this form. Keep a copy for your records.


1.     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.


2.     What you Agree to

2.1   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.

2.2   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,” and

§   Section 6, “Direct Compensation – Property Damage Coverage.”

2.3   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 (Optional)”

·          All Perils, but only for loss or damage caused by Collision or Upset, and

·          Collision or Upset.

2.4   We may choose to refund a portion of your premium when you sign this change or when we reinstate your coverages.

2.5   We will not pay a refund if you suspend your coverage for less than 45 consecutive days.

3.     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 same.



Signature of Insured






Effective (1995-04-01)

FSCO (1300E)

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