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

FORM BMC-35 

OMB No.: 2126-0017  Expiration: 02/28/2022

USDOT Number:

Date Received:

Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this
form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire.
For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division.
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 2126-0017. 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.

United States Department of Transportation
Federal Motor Carrier Safety Administration

Notice of Cancellation
Motor Carrier Insurance under 49 U.S.C. 13906

FORM BMC-35

Check coverage cancelled:
Cargo: BMC-34
Public Liability: BMC-91
from $
to $

BMC-91X

This is to advise that, under the terms of a policy or policies issued to:
(Name of Motor Carrier)
(Street)

by:

(City)

(State)

(Zip)

(City)

(State)

(Zip)

(Name of Insurance Company)
(Street)

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

,

, 12:01 a.m., standard time at the address of the insured as stated in said policy

31st
30th
29th
28th
27th
26th
25th
24th
23rd
22nd
21st
20th
19th
18th
17th
16th
15th
14th
13th
12th
11th
10th
9th
8th
7th
6th
5th
4th
3rd
2nd
1st
December
November
October
September
August
July
June
May
April
March
February
January
or policies, provided said date is not less than thirty (30) days after the receipt of this notice by the FMCSA.
(Insurance Company Policy Number)
(Name of authorized representative)
(Signature of authorized representative)
(Date of signature)

Filings must be transmitted online via the Internet at http://www.fmcsa.dot.gov/urs.

FORM BMC-35 Page 1 of 1

Rev 01/03/21