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Lien Holder
Vehicle Information
*Current Mileage must be provided at time of cancellation request.

Customer Request for Cancellation

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 d ate.

Authorize Cancellation