Your First name/Last name

Address

Postal code/ CITY

[Name of your insurance company]

Address

Postal code/ City

Done in [your city], on [specify the date].

Subject: Request to cancel my insurance contract no. [indicate your contract number]

Madam, Sir,

I subscribed to your company’s insurance contract no. [indicate your contract number] on [indicate the subscription date]. I now wish to terminate this contract on its anniversary date, that is, on [indicate the annual renewal date].

In accordance with Article L. 113-12 of the Insurance Code, I am sending you my termination request at least two months before the annual renewal date.

I kindly request that you send me a certificate confirming the termination.

While awaiting your reply, please accept, Madam, Sir, the expression of my best regards.

[Your signature]