Request For Gap Cancellation Form
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1PARTNERS ALLIANCE CORPORATION
· F
R
F
GAP C
: (858) 218-1469
EQUEST
OR
ANCELLATION
AX TO
Customer Information:
Name:
Policy Number (Or last 6 #’s of VIN):
Date Purchased:
Dealer Information:
Name of Dealer:
Contact Name:
Fax/Telephone Number:
Reason for Cancellation (check appropriate box below):
Requested Date of Cancellation:
Customer Request -
attach dated and signed letter from the customer or have
customer sign and date below.
Vehicle Trade In -
attach a copy of odometer statement or new purchase agreement
showing trade in. Date must be on both.
Repossession -
attach copy of financial institution repossession letter with date.
Early Payoff -
attach copy of financial institution payoff letter with date.
Unwind -
request from dealer with copy of voided contract.
Date of Total Loss -
customer must sign below & a copy of DOL & Lien release
documents required.
PAC USE ONLY
All copies must be legible.
Form#:
A COPY OF THE POLICY
must be sent in with this cancellation form.
Fee:
Do not deduct cancellations from transmittal forms.
VIN chk: Y / N
No refund will be paid if there is a claim against the Policy.
If the Policy is cancelled it cannot be reinstated.
Initial:____________
No refund will be forthcoming if the refund is $1.00 or less.
By your signature below, you are hereby requesting cancellation of your participation in
our guaranteed auto protection program. You agree that no further benefits are due to you
under the terms of your GAP addendum or GAP Insurance policy, except for partial refund
the purchase charge.
Customer Signature:
Printed Name:
Date:
Partners Alliance Corp., PO BOX 1630, Poway, CA 92074-1630 • GAP Cancels Fax 858-218-1469
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