Cancellation Request Form

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 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 benefits and services.

Note: Please be aware that premium and dues can't be refunded in a month in which a claim was field.

UBA Membership Plans are separate from any other insurance or supplemental plan you might have purchased. Please contact your agent for any plans other than a UBA Membership Plan.