Form BMC-35 Notice of Cancellation Motor Carrier Insurance Under 49

U.S. DEPARTMENT

OF TRANSPORTATION

A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-007. Public reporting for this collection of information is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590.

Form BMC 35 Approved by OMB

NOTICE OF CANCELLATION 2126-0017

To be sent to­: MOTOR CARRIER INSURANCE UNDER 49 U.S.C. 13906 Expires: 02/28/2009

Filed with

FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION FMCSA Docket No.

FMCSA Commercial Enforcement Division MC _____________

Commercial Enforcement Division Washington, D.C. 20590 FF______________

MC-ECC (W63-105)

1200 New Jersey Ave S.E.

Washington, D.C. 20590

Filer Account No.________________________________

Received: CHECK COVERAGE CANCELED:

Date: ­ Cargo: BMC 34 

Public Liability: BMC 91 

This is to advise that, under the terms of a policy issued to: BMC 91X 

$ To

____________________ (NAME OF MOTOR CARRIER)

____________________________________________________________________________________________________________________________ (ADDRESS OF MOTOR CARRIER)

­

by _________________________________________________________________________________________________________________________ (NAME OF COMPANY)

­ HOME OFFICE ADDRESS OF COMPANY)

the endorsement(s) and certificate(s) issued in connection therewith, as indicated herein, are hereby canceled, effective as of the day of

, , 12:01 a.m. standard time at the address of the Insured as stated in said policy or policies provided said date is not

less than thirty (30) days after the receipt of this notice by the FMCSA.

Insurance Company Policy No.­ (POLICY NUMBER) (SIGNATURE OF AUTHORIZED REPRESENTATIVE)

____________________________________________

(Date)