1680-01-01-.13
Notice Of Cancellation Of Air Carrier Insurance Policies
Cite as Tenn. Comp. R. & Regs. 1680-01-01-.13
NOTICE OF CANCELLATION
OF
AIR CARRIER INSURANCE POLICIES
(Executed in Triplicate)
Check Type Cancelled
BI and PD
Cargo
Filed with Tennessee Bureau of Aeronautics
This is to advise that under the terms of a policy or policies
issued to _________________________________________________________________________________
(Name of Air Carrier)
of ______________________________________________________________________________________
(Address of Air Carrier I
by ______________________________________________________________________________________
(Name of Company)
of ______________________________________________________________________________________
(Address)
said policy or policies, including any and all endorsements forming a part thereof or certificates issued in connection
therewith, is (are) hereby canceled effective as of the day of ____________19 ___, 12:01 a.m., standard time at the
address of the Insured as stated in said policy or policies provided such date is not less than thirty (30) days after the
actual receipt of this notice by the Bureau.
_______________________________________
Signature of Insuror
Insurance Company File No. _________________________
TBA Form E
Revised 5/74