BI-362 07/08 Return completed form to: Cancellation Request / Policy Release BrickStreet Mutual Insurance P. O. Box 3064 Charleston, WV 25334-3064 1.866.45BRICK Date (Month / Day / Year) Insured Name and Address Company Name and Address Cancelled Policy Information Cancellation Date 12:01 A.M. Policy Term Information Effective Date Expiration Date Policy Release Statement The Undersigned agrees that: No claims of any type will be made against the Insurance Company, its agents or its representatives, under this policy for losses which occur after the date of cancellation shown above. The insurance commissioner will be notified within 24 hours or by the end of the next business day, whichever is later, of your lapse of coverage. Any premium adjustment will be made in accordance with the terms and conditions of the policy. Name of Insured (Printed) Signature of Insured Date Reason for Cancellation Requested by Insured Succeeded or Merged Business Closed Other (Identify) Remarks: For BrickStreet Use Only Method of Cancellation Flat Short Rate Pro Rata Premium Calculation Subject to Audit BrickStreet Mutual Insurance  P.O. Box 3064  Charleston, WV   25334-3064  1.866.45BRICK American LegalNet, Inc. www.FormsWorkflow.com