Cancellation Request Form printable pdf download

Mechanical Protection Plan/ Old United

P.O. Box 634, Shawnee Mission, Ks. 66201‐0634

CANCELLATION REQUEST FORM

All information must be filled out completely and legibly to process this cancellation request

Any information omitted may delay the cancellation process. All cancellations will be processed within 30 days of receipt.

CUSTOMER INFORMATION

______________________________________________________________________________

Name

Last

Middle Initial

First

______________________________________________________________________________

Address

______________________________________________________________________________

City, State & Zip Code

________________________

_____________________________________________

Area Code/Phone #

Email Address

VEHICLE INFORMATION

______________________________________________________________________________

Year, Make & Model

______________________________________________________________________________

Last 6 digits of Vehicle ID # (VIN)

LIENHOLDER INFORMATION

Is there a lien on the vehicle

Yes

_____________________________________

________________________________________

Lienholder Name

Account #

____________________________________________________________________________________

Lienholder Address

1 Cancellation requests received on vehicles that are still secured by a lien must have the lienholders name, address, and account number included on this

ALL REFUNDS ON VEHICLES THAT ARE STILL SECURED BY A LIEN WILL BE PAID DIRECTLY TO THE LIENHOLDER.

cancellation request form.

2 Cancellation requests received on vehicles that have had the lien paid off or released must have attached proof of release of lien, copy of clear title or lien release

IF NOT INCLUDED, ANY REFUND DUE WILL GO TO THE LIENHOLDER ON FILE.

letter from lienholder.

Flat cancellation may be provided if cancellation is done within 30 days of purchase date and a claim has not been filed.

PLAN(S) TO BE CANCELLED

Please check all boxes that apply (boxes left blank will not be cancelled)

Club Plus

Platinum Plus

Mechanical Service Agreement Maintenance

Lease Wear

Gap

OnGard

PDR (Paintless Dent Repair) TireAssure

Credit Insurance

Other:__________________________________________________________________________________________________________________________________

Lojack, Skylink, Skyway, Theft guarantee cancellations can only be processed if the UNIT has not been installed and the cancel request MUST be received from the

dealer. Zaktek is non‐cancelable.

REASON FOR CANCELLATION

Vehicle Traded In – (Include odometer statement) Total Loss – (Need loss paperwork from insurance Company) Customer Request

Sold Vehicle – (Include odometer statement or bill of sale)

Paid in Full – (include paid in full letter)

Other:__________________________________________________________________________________________________________________________________

Cancellation Mileage _____________________________________Cancellation Date ___________________________________(if other than today’s date see below)

We reserve the right to verify and document date and mileage. For cancellation refunds on clear liens, distribution of cancellation refunds other than described

herein must have separate, customer signature‐endorsed instructions. Dealer signature only required on unwind or re‐contracted transactions.

Form sent in by

Customer

Dealer Lienholder

Dealer Name

__________________________________________ Customer Name

______________________________________________________

Dealer Signature

__________________________________________ Customer Signature

______________________________________________________

Dealer Signature

__________________________________________ Date Signed