Contract Cancellation Form
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1Contract Cancellation Form
To be completed and signed by the Contract Holder and the Dealer
Complete all sections of this form. Incomplete forms and missing documents will greatly delay the cancellation request.
Contract Holder
Selling Dealer
Name
Name
Address
Address
City
City
State
Zip Code
State
Zip Code
Phone Number
Phone Number
Fax Number
Cancellation of coverage requested for the following products. Please check all that apply.
(See product form for details and cancellation rules by state.)
Vehicle Service Contract
GAP
Other________________
Maintenance
Security Guard
Tire & Wheel
Vehicle and Contract Information
VIN
Date Contract
Date Cancellation
Number
Purchased
Requested
Vehicle Mileage at
Vehicle Mileage
Contract Purchase
at Cancellation
Loan Information
Yes
No
Financial Institution paid in full?
Indicate to whom the refund should be paid. If loan paid in full, include proof of payoff with the request.
Name
Address
City
Zip Code
State
Reason for Cancellation
Please check one (1) of the following and attach required documents.
Contract Holder Request-Attach Contract Holder copy of Contract. If unavailable, Contract Holder must put request in writing in the space below.
Repossession - Attach copy of repossession papers from Financial Institution.
Total Loss - Attach copy of Total Loss Report. (Not applicable to GAP coverage)
Unwind - Attach Contract Holder copy of Contract and provide a brief explanation for flat cancellation in the space provided below.
Other - Please explain in provided space below.
Comments/Additional Information
Signatures Required
Cancellation Request must be signed by the Contract Holder and Dealer Representative, or include supporting documentation showing reason for cancellation.
Contract Holder's
Dealer's Representative
Signature
Date
Signature
Date
PO Box 7922, Shawnee Mission, KS 66207
Toll-Free (888) 805-1594 or Fax (913) 664-3247
V23150CL (03/11)
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Parent category: Legal