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UNIVERSAL INSURANCE CANCELLATION REQUEST
1
WHO IS SUBMITTING THIS CANCELLATION
*
This field is required.
Must be at least one name listed on the title
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CUSTOMER
UNIVERSAL EMPLOYEE
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Please Select
CUSTOMER
UNIVERSAL EMPLOYEE
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2
Main Customer Contact Email
*
This field is required.
example@example.com
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3
STATUS OF LOAN
*
This field is required.
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UNIVERAL IS PAYING OFF
ANOTHER DEALER IS PAYING OFF
VEHICLE HAS NO LOAN AND IS CURRENTLY PAID OFF
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UNIVERAL IS PAYING OFF
ANOTHER DEALER IS PAYING OFF
VEHICLE HAS NO LOAN AND IS CURRENTLY PAID OFF
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4
CHOOSE ITEM(S) REQUESTING FOR CANCELLATION
*
This field is required.
TIRE AND WHEEL COVERAGE
GAP
SERVICE CONTRACT / WARRANTY
MAINTENANCE POLICY
KEY REPLACEMENT / DOOR DING COVERAGE
Other
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5
EXPECTATION OF CANCELLATION REFUND
DEALER RETAINS TO UTILIZE IN RECENT TRANSACTION
FORWARD TO CUSTOMER
FORWARD TO LOAN COMPANY
FORWARD TO THE INSURANCE COMPANY
Other
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6
POLICY HOLDER NAME
*
This field is required.
Who's Name Is First On The Title?
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7
YEAR AND MAKE OF VEHICLE
*
This field is required.
If multiple vehicles are involved, please issue cancellation request separately
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8
VIN NUMBER
*
This field is required.
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9
ODOMETER READING AT CANCELLATION DATE
*
This field is required.
Must Be Exact
This is only required if a Service Contract or Maintenance Policy is being cancelled
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10
CANCELLATION DATE REQUESTED
*
This field is required.
This can reflect the date of an accident if and when you sold or traded the vehicle
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11
PLEASE DESCRIBE REASON OF PRODUCT CANCELLATION(S)
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12
NAME OF LOAN COMPANY
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13
COMMENTS / ADDITIONAL INFORMATION
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14
UPLOAD PROOF OF PAID-OFF LOAN AND THE ODOMETER STATEMENT
We only proof of paid loan if orginal insurance was purchased with a loan
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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Can also be accepted in seperate email
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15
SIGNATURE OF CUSTOMER REQUESTING CANCELLATION
*
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By signing this cancellation request I acknolwedge I relinquish all rights and provisions of coverageges being cancelled and all cancellations are final and coverage cannot be reinstated for reason per the insurancey companies.
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16
SIGNATURE OF DEALER EMPLOYEE REQUESTING CANCELLATION
*
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By signing this cancellation request I acknolwedge that I have received the customer's consent and explained the terms and conditions of the cancellation process
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