Insurance Binder Cancellation Form

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DOCUMENT NO.
KENTUCKY TRANSPORTATION CABINET
TC-96-30
Division of Motor Vehicle Licensing
9/96
MOTOR VEHICLE INSURANCE AGENT
INSURANCE BINDER CANCELLATION FORM
IMPORTANT – Per KRS 304.39-083, “If the owner of a motor vehicle has been issued a binder or other contract for temporary
insurance for motor vehicle security, and subsequently contacts the agent who issued the binder or other contract for temporary
insurance to cancel the motor vehicle security before the agent has forwarded the person’s application for a binder or other contract for
temporary insurance to the insurance company, the agent shall immediately notify the Department of Vehicle Regulation that the
owner has cancelled the binder for motor vehicle security”.
(PLEASE PRINT OR TYPE ALL INFORMATION REQUIRED BELOW)
INSURANCE AGENCY SECTION
AGENCY
NAME:________________________________________________________________________
ADDRESS:_____________________________________________________________________
CITY:______________________________________ STATE:_________ ZIP:________________
COUNTY:________________________ AGENT NAME:_________________________________
AGENT NO:_____________ TELEPHONE NO: (
)____________ FAX: (
)______________
INSURANCE COMPANY SECTION
COMPANY NAME:__________________________________ NAIC CO. CODE:______________
_______________________________________________________________________
INSURED/POLICY HOLDER SECTION
INSURED NAME:_______________________________________________________________
ADDRESS:____________________________________________________________________
CITY:______________________________________ STATE:_________ ZIP:_______________
COUNTY: ______________________________________
HOME TELEPHONE NO: (
)________________ BIRTH DATE: (MM/DD/YY)______________
KY DRIVER LICENSE NO:________________________________________________________
MOTOR VEHICLE(S) SECTION
VEH 1 – YEAR: ___________ MAKE: ___________
VIN:
VEH 2 – YEAR: ___________ MAKE: ___________
VIN:
VEH 3 – YEAR: ___________ MAKE: ___________
VIN:
VEH 4 – YEAR: ___________ MAKE: ___________
VIN:
VEH 5 – YEAR: ___________ MAKE: ___________
VIN:
BINDER/POLICY SECTION
BINDER/POLICY NO: ____________________________________________________________
BINDER EFFECTIVE DATE: ______________ BINDER CANCELLATION DATE: _____________
AGENT SIGNATURE: _____________________________________ DATE:_________________
FAX: (502) 564-9314
MAIL: Transportation Cabinet, Division of Motor Vehicle Regulation, PO Box 2014, Frankfort, Ky 40622

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