Great Lakes Mutual

Policy Services Forms

All form fields must be completed except where noted. Incomplete form fields will not allow the form to be submitted to Great Lakes Mutual Insurance.

Request for Policy Cancellation

Policy Information

Policy Number

Insured Information

First Name


Last Name

Mailing Address

Mailing Address Line 2 (optional)


Zip Code

Property Address

Property Address Line 2  (optional)


Zip Code

Phone Number (required for call back)

Email Address

Cancellation Information

Reason for Cancellation

Enter Effective Date of Cancellation

TIME: 12:01 AM Standard Time

Cancel Policy

By checking the box above, I hereby request that my policy be cancelled on the date entered above, and attest that the information provided is true, complete and correct to the best of my knowledge and belief.

Verification Code

Retype Code