CANCELLATION REQUEST

CANCELLATION Form

Contractor Details

Contract #

Contract Type

Contract Holder’s Name

Street Address

City

State

Zip

Telephone

Contractor Lienholder Details

Lienholder

I have no lienholder.

Telephone

Dealer Details

Dealer Name

Street Address

City

State

Zip

Telephone

Dealer Lienholder Details

Location (Branch)

Lienholder Account Number

Telephone

Contract Purchase Date

Cancel Effective Date

Mileage at Issue

Cancellation Mileage

Year

Make

Model

Vehicle Identification Number

Current Mileage must be provided at the time of cancellation request

REASON FOR CANCELLATION (Check One)

Customer Request – We must have the customer’s signature or a letter from the customer requesting cancellation. Trade in or Sale – A copy of the Odometer Statement, copy of sales documentation and proof of payoff is required. Theft or Total Loss – Attach supporting documentation for date/mileage. Repossession – A copy of the repossession letter from the lienholder is required. Flat Cancel/Unwind – Cancellation request must be received in our office within 60 days from Contract Purchase Date.

I hereby request cancellation of my Extended Service Contract (“Contract”) described above. In consideration of this cancellation, I do hereby release the Service Contract Provider (“Dealer”) and the Service Contract Administrator (“Administrator”), and I agree to hold the Dealer and Administrator harmless from any and all claims, demands, actions and payments on account of the Contract, except for the refund that will calculated per the cancellation terms on the Contract. I further understand and accept that this cancellation will completely VOID all protection provided by the contract and cannot be reinstated for any reason after the cancellation date.

Customer

Date

Customer Email

Cancellation Email: Cancellations@dealerloyaltyprotection.com

Dealer must submit all required cancellation paperwork: Cancellation Request Form, Copy of Contract and any other supporting documents to our office within 30 days of Cancellation to be processed without penalty. All incomplete requests, missing informationor supporting documents will be returned unprocessed and will delay refund. Please allow 4-6 weeks to receive cancellation refund.

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CANCELLATION REQUEST

CANCELLATION Form

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