Cancellation Request Form

Company Name

Today's date *

- Month - Day Year

Original Date of Purchase *

- Month - Day Year

Request of Cancellation *

Cancellation for future drafts only Cancellation and Refund (first 30 days)

Full Name *

First Name Last Name

E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

Reason for Cancellation and Comments *

Refund Policy: If you are not completely satisfied with your UBA Gap Plan, please call us at 866-438-4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisifed with your UBA Gap Benefits.

Note: For any new membership plans purchased between 2/4/16 through 10/5/16 with monthly credit card drafts, there will be a $2.50 per month, non-refundable administration fee. This fee will not be imposed on monthly bank draft membership plans.