Notices of Cancellation / Nonrenewal and / or Other Related Forms
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1 Forms are listed alphabetically by form title. INDEX POLICY CODES 1. Auto 2. Fire and Multiple Peril 3. Liability 4. Property, other than Fire and Multiple Peril (e.g. Crime & Inland Marine) 5. Workers Compensation 6. Fidelity & Surety 7. Motorcycle Only 99. All lines and coverages where the state laws and regulations or the specific policy provisions do not have special requirements precluding the use of a generic termination AR. Assigned Risk Policies C. Commercial Lines Only P. Personal Lines Only PAGE CN 1 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
2 USE WHEN SPECIFIC STATE "NOTICE" IS NOT APPLICABLE (The following forms may apply only where state laws and regulations and/or specific policy provisions do not have requirements precluding the use of generic termination forms.) * (N) GU8811 D 01/00 99 NOTICE OF CANCELLATION, GU /98 5 NOTICE OF CANCELLATION, OF WORKERS' COMPENSATION (R) GU560 A 08/03 1, 2, 3, 4, 5, 6 REINSTATEMENT NOTICE (FOR CANCELLATION OR NON) GU275 05/85 1, 2, 3, 4, 5, 6 REINSTATEMENT NOTICE (FOR PRIOR NOTICE OF CANCELLATION) SPECIFIC STATE NOTICES Alabama GU8851 H 09/03 1, 2, 3, 4 NOTICE OF CANCELLATION, OR DECLINATION Alaska GU418 C 03/04 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, GU543 09/99 NOTICE OF RIGHT TO NAME DESIGNEE (FOR INSUREDS 70+) GU /04 1P, 2P, 3P, 4P RECONSIDERATION CERTIFICATION Arizona GU401 E 06/08 2, 3, 4 NOTICE OF CANCELLATION, OR DECLINATION GU9532 M 01/09 1 NOTICE OF CANCELLATION, NON, DECLINATION OR AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AK, AL, AR, AZ, CO, CT, DC, DE, HI, IA, ID, IN, KS, KY, LA, MA, ME, MI, MO, MT, NC, ND, NE, NH, NM, NY, OH, OK, OR, PA, SC, SD, TX, VA, VT, WA, WI, WV, WY AK, AL, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY PAGE CN 2 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
3 REDUCTION IN POLICY LIMITS Arkansas GU8949 H 01/04 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, NON OR INCREASE IN POLICY PREMIUM California GU351 H 05/06 1C, 2, 3, 4, 5 NOTICE OF CANCELLATION, OR CHANGE IN POLICY PREMIUM/TERMS GU8691 K 05/06 1P NOTICE OF CANCELLATION, NON, OR DECLINATION OF Colorado GU402 C 07/02 1C, 2, 3, 4, 6 NOTICE OF CANCELLATION, GU6901 B 07/02 1P NOTICE OF CANCELLATION, NON, PROPOSED REDUCTION IN OR INCREASE IN PREMIUM GU6901 C 11/10 1P NOTICE OF CANCELLATION, NON, PROPOSED REDUCTION IN OR INCREASE IN PREMIUM Connecticut GU /01 3C AVAILABILITY OF EXTENDED REPORTING PERIOD GU403 F 09/03 1C, 2C, 3C, 4C, 5 NOTICE OF CANCELLATION, NON OR DECLINATION GU8592 K 09/08 1P, 2P, 3P, 4P NOTICE OF CANCELLATION, NON GU /01 1, 2, 3, 4 PREMIUM BILLING NOTICE Delaware GU6854 H 08/06 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, NON, OR DECLINATION OF GU /06 2 NOTICE REGARDING REPLACEMENT OF PROPERTY (FIRE) District of Columbia GU404 N 09/08 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION OR NON Florida GU /09 5 NOTICE OF CANCELLATION OR NON OF WORKERS' COMPENSATION (FLORIDA) GU8817 S , 2, 3, 4 NOTICE OF CANCELLATION, NON, PREMIUM AND DECLINATION OF OR POLICY TRANSFER Georgia C59 N 06/08 2, 3, 4, 5 NOTICE OF CANCELLATION, PREMIUM/PROVISIONS GU6643 P 08/97 1 NOTICE OF CANCELLATION, NON, DECLINATION OF PAGE CN 3 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
4 OR CHANGE IN POLICY PREMIUM/PROVISIONS Idaho GU8923 D 07/97 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, Illinois GU8860 S 12/03 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, NON, DECLINATION, OR CHANGE IN POLICY PREMIUM/ Indiana GU6214 G 04/04 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, NON GU /07 2P NOTICE OF REDUCTION, RESTRICTION OR REMOVAL OF GU /07 2 NOTICE REGARDING THE USE OF A CONSUMER REPORT Iowa GU8903 M 06/04 1P NOTICE OF CANCELLATION OR NON OF AUTOMOBILE (IA) GU406 C 06/04 1C, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION OR, OR DECLINATION Kansas GU8892 P 04/06 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, NON, OR DECLINATION OF Kentucky GU8507 K 09/08 1, 2, 3, 4, 6, 99 NOTICE OF CANCELLATION,, DECLINATION OF OR POLICY EXPIRATION Louisiana GU385 F 10/09 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, Maine GU9660 K 03/06 1, 2, 3, 4, 5 NOTICE OF CANCELLATION,, IMPENDING NON OR DECLINATION Maryland GU /08 1P IMPORTANT CONSUMER NOTICE UA223 09/01 1 IMPORTANT NOTICE RELATING TO A CANCELLATION OR NON OF AUTOMOBILE AL6247 P 06/09 1P NOTICE OF CANCELLATION OR NON GU6743 C 08/08 2, 3 NOTICE OF CANCELLATION OR NON OF LEAD LIABILITY OR REIMPOSITION OF LEAD HAZARD EXCLUSION GU552 E 01/10 5 NOTICE OF CANCELLATION, PAGE CN 4 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
5 OF WORKERS' COMPENSATION GU421 K 02/10 1C, 2, 3, 4 NOTICE OF CANCELLATION, / GU6906 C 08/00 1 NOTICE OF CANCELLATION, NON OR REDUCTION IN /INCREASE IN PREMIUM GU6915 B 06/09 1P NOTICE OF PREMIUM INCREASE (15% OR LESS) GU6916 D 06/09 1P NOTICE OF PREMIUM INCREASE (GREATER THAN 15%) GU6929 B 06/09 1P NOTICE OF REDUCTION IN GU /06 1C, 2C, 3C, 4C OFFER TO REINSTATE POLICY Massachusetts GU /97 1P, 2P, 3P, 4P IMPORTANT CONSUMER NOTICE REGARDING CONSUMER REPORTS GU9740 E 03/09 1 LEGAL NOTICE OF NON OF YOUR MASSACHUSETTS AUTOMOBILE POLICY GU439 D 06/10 1 NOTICE OF CANCELLATION FOR COLLISION AND COMPREHENSIVE GU6913AMAREG 03/09 1C NOTICE OF CANCELLATION OF THE MASSACHUSETTS AUTOMOBILE POLICY -- REGISTRAR'S COPY (CH 90:5 ONLY) GU /04 5 NOTICE OF CANCELLATION OR NON OF WORKERS' COMPENSATION GU /04 99 NOTICE OF CANCELLATION, C60 H 09/04 2, 3, 4 NOTICE OF CANCELLATION, NON GU6913 A 03/09 1 STATUTORY NOTICE OF CANCELLATION OF THE MASSACHUSETTS MOTOR VEHICLE LIABILITY POLICY (PERSONAL) GU /02 1 STATUTORY NOTICE OF CANCELLATION OF THE MASSACHUSETTS MOTOR VEHICLE LIABILITY POLICY (PERSONAL) Michigan GU8819 Q 11/03 1, 1C, 2C, 3, 4C, 6 NOTICE OF CANCELLATION OR NON (APPLIES TO POLICIES NOT SUBJECT TO CHAPTER 21) WC7687 J 07/09 5 NOTICE OF TERMINATION OF LIABILITY GU8510 G 10/08 1P, 2P NOTICE OF TERMINATION OR DECLINATION OF Minnesota GU /05 5 IMPORTANT NOTICE REGARDING REQUIREMENT TO MAINTAIN WORKERS COMPENSATION C73 K 09/04 1C, 2, 3, 4, 6 NOTICE OF CANCELLATION, (MINNESOTA) GU8912 P 09/04 1 NOTICE OF CANCELLATION, NON, OR REDUCTION PAGE CN 5 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
6 OF POLICY LIMITS - PERSONAL AUTOMOBILE, MOTORCYCLE POLICIES, AND COMMERCIAL AUTOMOBILE POLICIES INSURING FEWER THAN FIVE VEHICLES (MINNESOTA) GU /97 1, 2, 3, 4 NOTICE REGARDING PREMIUM FINANCED POLICY Mississippi GU6817 A 05/01 5 NOTICE OF CANCELLATION OR NON OF WORKERS' COMPENSATION GU8871 H 07/98 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, NON OR REDUCTION IN Missouri GU8694 N 10/08 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, NON, REDUCTION IN POLICY LIMITS, ADVERSE MODIFICATION OR DECLINATION OF GU6910 A 01/02 1C, 2C, 3C, 4C, 6 NOTICE OF CONDITIONED GU6909 A 12/01 1 NOTICE OF INCREASE IN PREMIUM DUE TO ACCIDENT CLAIMS Montana GU6707 E 05/04 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, NON, WITH ALTERED TERMS OR DECLINATION OF Nebraska GU8758 G 08/97 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION OR NON GU /08 1, 2, 3, 4, 5, 6 NOTICE OF REDUCTION Nevada GU409 E 08/04 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, - NEVADA New Hampshire GU8586 P 06/10 1, 2, 3, 4 NOTICE OF CANCELLATION OR NON- (NEW HAMPSHIRE) WC8001 J 05/92 5 TERMINATION NOTICE New Jersey FORM116B 07/09 5 APPROVED FORM FOR FILING NOTICE OF CANCELATION BY CARRIER FORM117A 07/09 5 APPROVED FORM FOR FILING NOTICE OF REINSTATEMENT GU6016 DEPARTMENT OF (NJ) GU6009 J 04/11 1C, 2, 3, 4 NOTICE OF CANCELLATION, NON OR POLICY GU9507 U 04/11 1P NOTICE OF CANCELLATION, New Mexico GU9768 G 05/09 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, LIMITS/FORM New York GU /02 3C PAGE CN 6 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
7 AVAILABILITY OF EXTENDED REPORTING PERIOD GU554 A 08/07 1C, AR NOTICE OF CANCELLATION OR NON - FOR HIRE-ASSIGNED RISK PLAN AUTOMOBILE GU553 C 08/07 1, AR NOTICE OF CANCELLATION OR NON-ASSIGNED RISK PLAN AUTOMOBILE GU555 B 09/10 7, AR NOTICE OF CANCELLATION OR NON-MOTORCYCLE-ASSIGNED RISK POLICY GU6683 F 08/07 1P NOTICE OF CANCELLATION, GU548 D 08/07 7P NOTICE OF CANCELLATION, -PERSONAL MOTORCYCLE GU323 K 08/06 2C, 3C, 4C NOTICE OF CANCELLATION, OR CHANGE IN TERMS, CONDITIONS OR RATES GU550 C 08/07 1C NOTICE OF CANCELLATION, OR CHANGE IN TERMS, CONDITIONS OR RATES - FOR HIRE VEHICLES GU6512 U 08/07 1C NOTICE OF CANCELLATION, OR CHANGE IN TERMS, CONDITIONS OR RATES - NEW YORK C35 X 11/06 2P, 3P, 4P NOTICE OF CANCELLATION,, SUBSTITUTE POLICY OR CHANGE IN POLICY LIMITS/ (NEW YORK) GU /97 NOTICE OF RECISSION North Carolina GU8514 A 07/97 1P NOTICE OF AMENDMENT GU6637 N 09/08 1P NOTICE OF CANCELLATION OR REFUSAL TO RENEW GU400 C 05/02 1C, 2, 3, 4 NOTICE OF CANCELLATION, North Dakota GU426 E 04/06 1, 2, 3, 4 NOTICE OF CANCELLATION, - NORTH DAKOTA Ohio GU8879 F 08/04 1P NOTICE OF CANCELLATION, NON GU405 D 08/04 1C, 2, 3, 4 NOTICE OF CANCELLATION, PAGE CN 7 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
8 Oklahoma GU408 E 11/02 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, OR DECLINATION Oregon WC /10 5 CANCELLATION AND NON NOTICE WC8671 B 03/04 5 CANCELLATION NOTICE GU8940 J 06/04 1, 2, 3, 4 NOTICE OF CANCELLATION, - OREGON WC8672 A 07/03 5 REINSTATEMENT OF GUARANTY CONTRACT (FOR WORKERS COMPENSATION POLICY AND RELATED GUARANTY CONTRACT) Pennsylvania C62 H 12/09 2, 3P, 4P NOTICE OF CANCELLATION OR REFUSAL TO RENEW (COMMERCIAL USE ONLY FOR COMMERCIAL FARMOWNERS) GU8797 R 12/09 1P NOTICE OF CANCELLATION OR REFUSAL TO RENEW OR REFUSAL TO WRITE GU312 H 05/04 1, 2C, 3C, 4C, 5, 6 NOTICE OF CANCELLATION, NON, DECLINATION OR INCREASE IN POLICY PREMIUM (APPLIES ALSO TO PERSONAL AND COMMERCIAL AUTO ASSIGNED RISK POLICIES) Rhode Island GU8701 H 01/10 1 NOTICE OF CANCELLATION OR NON GU458 D 06/08 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, GU /08 2, 3, 4, 5, 6 NOTICE OF CONDITIONAL GU6937 A 01/10 2, 3, 4, 5, 6 NOTICE OF CONDITIONED GU /08 1 NOTICE OF REDUCTION IN LIMITS OR CON DITIONED South Carolina GU8639 F 03/99 1 NOTICE OF CANCELLATION OR NON OF AUTOMOBILE GU547 E 03/11 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, South Dakota GU422 D 04/04 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, NON, OR DECLINATION Tennessee GU6004 H 06/05 1, 2, 3, 4, 5 NOTICE OF CANCELLATION, Texas GU407 C 01/01 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, NON Utah GU8590 D 08/97 1, 2, 3, 4, 5, 6 PAGE CN 8 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
9 NOTICE OF CANCELLATION, Vermont GU433 C 08/02 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, NON OR Virginia GU6006 A 08/97 3P, 4P NOTICE OF CANCELLATION OR NON GU6652 T 03/04 1P NOTICE OF CANCELLATION OR REFUSAL TO RENEW - AUTOMOBILE C58 Q 11/06 2P, 4C NOTICE OF CANCELLATION OR REFUSAL TO RENEW, DECLINATION OR CHANGE IN POLICY GU313 K 11/06 1C, 2C, 3C, 4C NOTICE OF CANCELLATION, REFUSAL TO RENEW OR CHANGE IN POLICY Washington GU8914 P 09/07 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, NON, POLICY / CHANGE IN POLICY/RATES/PROVISIONS OR DECLINATION OF West Virginia GU8815 M 12/06 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, NON Wisconsin GU6639 P 06/04 1, 2, 3, 4, 5, 6 NOTICE OF CANCELLATION, NON OR ALTERED POLICY TERMS OR PREMIUM Wyoming GU374 D 09/05 1, 2, 3, 4, 6 NOTICE OF CANCELLATION, PAGE CN 9 of 9 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
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