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) City Zip Code Property Address Property Address Line 2 (optional) City 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 Police Department Name Police Report Number 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
