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

UBA Products to Cancel (select all that apply)

UBA Membership Optional UBA Gap Membership Product that includes Group Insurance Optional a la carte Benefit Boost Subscription Products (list product in comment below)

Reason for Cancellation and Comments *

Refund Policy: UBA's refund and cancellation policy is the following: If you are not completely satisfied with your UBA Product(s), please call your Personal Member Concierge 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.

Please be aware that if you purchased any additional optional supplemental products through UBA that included Group Insurance programs, premiums and dues cannot be refunded if a claim was filed.

Note: This membership is separate from any other insurance or supplemental plans you have purchased. Please contact your agent for any plans other than the UBA Membership or any additional optional supplemental UBA Products that included group insurance, or the monthly subscription stand-alone non-insurance Benefit Boost family of products (Benefit Boost or Virtual PCP). If you are cancelling, please make sure to cancel using our cancellation phone number at 866-438-4274 or this cancellation form, or through the Member Portal.

Please do not cancel through your agent. Cancel directly with your Personal Member Concierge to make sure your cancellation request is handled promptly and correctly. We showcase our name UBA GAP and our number 866-438-4274 on all transactions on your account statement and it is your responsibility to check the transactions occuring on your account every month and to cancel with us when desired. Every month we pay for the membership services and the insurance premiums for any applicable optional supplemental group insurance programs on your behalf, whether you use the membership services or file a claim with the group insurance program.