Farmers Mutual Insurance Company
10925 Perry Highway
Wexford, PA 15090
Phone: (724)935-2940
Fax: (724)935-9269
fmmc@consolidated.net

Cancellation Request

If you are a human and are seeing this field, please leave it blank.

Fields marked with a * are required.

Insured Name *

Agent Name

Person completing this form

Phone *

Email *

Date Completed

Policy Number *

Requested effective date for change

Policy Needs Cancelled

Reasons

Remarks or special instructions pertaining to any of the above

This form is not to be used to transfer an insurance policy from one person to another nor to transfer a policy currently in force to another property location. A new application is required to accomplish either of these transactions. Contact must be made with your agent for this type of transaction.

Disclaimer: The change requested will not be effective until approved by underwriting. You will receive a new declaration page noting the change once approval has been granted. If you need coverage bound immediately, contact should be made directly with your agent. We will notify the agent of changes requesting an increase in coverage to obtain the proper photos and other information that may be necessary to evaluate and process this request.

I hereby certify that I have the authority to make this request by being the insured or a representative of the insured. *