Get Surcharge Revocation

This guide will help you complete the Surcharge Revocation form accurately and efficiently. Following these instructions will ensure that you provide all necessary information for a smooth processing of your revocation request.

Follow the steps to successfully fill out the Surcharge Revocation form.

1. Click 'Get Form' button to obtain the form and open it in an editor.
2. Provide the name of the insurance company in the appropriate field. This should match the company issuing the revocation.
3. Enter the full name of the operator for whom the Surcharge Revocation is issued in the operator name field.
4. Fill in the operator's address, including street, city, state, and zip code.
5. Input the operator's date of birth to confirm their identity.
6. Enter the operator's driver license number exactly as it appears on the document.
7. Provide the state code that corresponds to where the driver's license was issued.
8. Fill in the date of the accident related to the Surcharge Revocation.
9. Input the notice date of the accident on the designated field.
10. Enter the location code for the accident using the three-digit code provided in the guidelines.
11. Fill in the policy number related to the insurance coverage.
12. Provide the claim identification number for future reference.
13. Enter the standard of fault code as it appears on the original Surcharge Notice.
14. Provide a complete description of the standard of fault explanation corresponding to the previous field.
15. Input the policyholder's name, or enter 'SAME' if it matches the operator's name.
16. Fill in the policyholder's address, ensuring it corresponds with the previously entered name.
17. Enter the policyholder's date of birth as listed on the original Surcharge Notice.
18. Input the policyholder's driver license number as referenced previously.
19. Provide the state code related to the policyholder’s driver license.
20. In the 'Reason' section, describe the reason for the revocation clearly and concisely.
21. Enter the date of preparation for this Surcharge Revocation Notice.
22. Finally, ensure that an authorized representative of the insurance company signs the form, either with an original or electronic signature.

Complete your Surcharge Revocation document online for efficient processing.