Cancellation Request | Dealer Loyalty Protection

Contract Number

Coverage Name

Contract

Contract Holder’s Name

Street Address

City

State

Zip

Telephone

Dealer

Dealer Name

Street Address

City

State

Zip

Telephone

Lien Holder

I have no lein holder

Lienholder

Lienholder Account Number

Telephone

Location (Branch)

Contact

Vehicle Information

Contract Purchase Date

Cancel Effective Date

Mileage at Issue

Cancellation Mileage

Year

Make

Model

Vehicle Identification Number

*Current Mileage must be provided at 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.

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

Type Your Name

Customer Email

Date