# Affiliated FM Insurance Company

**Notice of Cancellation**

This notice is to inform you that the above policy has been CANCELLED in accordance with the conditions of the policy, effective on and after the hour and date shown above. Premium adjustment and settlement will be effected as soon as practicable (applicable to Property Fire Policies) or Reporting Policies upon receipt of final values from the Insured, the Policy will be adjusted and the required premium or billing of premium due will be effected.

You are hereby notified that the above policy will expire in accordance with the conditions of the policy, effective on and after the hour and date shown above and will NOT BE RENEWED.

Due to the cancellation or nonrenewal of your insurance coverages, you may wish to avail yourself of the services of the facility located at [insert location], either through your present broker or directly upon application to the above named facility.

**Other**

AUTHORIZED REPRESENTATIVE: [Signature]

**Affiliated FM Insurance Company**

Allendale Park  
P. O. Box 7500  
Johnston, Rhode Island 02910  
Cable ALLENDALE Telex 027500

**MORTGAGE Lien Holder**

**Excess This:**
**Policy Effective At:** May 21, 1980

**303**