Veritas GAP

APPI
ADVANCED PROTECTION PRODUCTS INTERNATIONAL
CANCEL REQUEST & RELEASE FORM
FAX Cancel Quote Requests to: (866) 778-9890

E-Mail Cancel Quote Requests to: gapadmin@appiadm.com

Call (888) 366-3774 for Cancel Quotes
Customer Name*

First NameLast Name
Customer Email*
example@example.com
VIN*
Vehicle Identification Number
Customer Address*

Address

Street Address Line 2

CityState

Zip
Requested Date of Cancellation*

MonthDayYear
Date
If "Customer Request" is selected above, please explain.
Customer RequestTrade-inEarly PayoffTotal Loss - No Claim FiledRepossessionRe-Write
GAP Contract Date*

MonthDayYear
Date
GAP Term*
Length of GAP Contract
GAP Price*
Length of GAP Contract
DealerLien HolderConsumer (Proof of payoff from lien holder is required to refund customer)
Back office email
example@example.com
Lender*
Lender Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Lender Address*

Address

Street Address Line 2

CityState

Zip
Dealer Location*
Finance Manager*
REQUEST FOR CANCELLATION OF GAP AGREEMENT
By Your signature below, you acknowledge that:

1. You understand that you have an unequivocal right to cancel the GAP Agreement at any time. If you cancel the GAP Agreement within sixty (60) days of the date of purchase, then you will receive a full refund of the GAP Agreement purchase price. If you cancel the GAP Agreement after sixty (60) days of the date of purchase, then the refund will be prorated based on the number of elapsed months since the GAP Agreement purchase date;

2.The requested cancellation date and the reason for the cancellation are shown above;

3.You understand that this form must be submitted to the Administrator identified below within thirty (30) days of the requested cancellation date;

4.You understand that any refund payment made to the lien holder will be deducted from the finance agreement's principal balance and that any such deduction may not reduce your monthly payment;

5.You understand that in the event of a total loss of your vehicle after the GAP Agreement has been cancelled, you will be solely responsible for Payment of the finance agreement's outstanding balance including any difference between the finance agreement's outstanding balance and any settlement payment made by your primary insurance carrier, as well as payment of a deductible, if applicable, and

I acknowledge that I have read and fully understand the terms and conditions of cancellation described herein. I understand that the GAP Agreement described above terminates once I sign and date this form. I hereby terminate the GAP Agreement as of the requested date of the cancellation above.
Consumer Signature*
Date*

MonthDayYear
Date
Dealer Signature
Signature Date

MonthDayYear
Date
Photo of Check
Consumer SignatureDealer Signature NOTE: If this request is for other than a cancellation due to repossession, the consumer MUST sign this form. All requests for cancellation due to repossession must be accompanied by proof of repossession by the lendor/lessor. Requested cancellation date cannot be any earlier than the date this form is completed and signed by the consumer. ATTENTION CONSUMER: TO PROCESS CANCELLATION, YOU MUST FORWARD THIS FORM OR OTHER WRITTEN NOTICE OF

CANCELLATION TO THE ADMINISTRATOR.

Advanced Protection Products International

PO Box 232437 I San Diego, CA 92193
Should be Empty:

APPI

ADVANCED PROTECTION PRODUCTS INTERNATIONAL

CANCEL REQUEST & RELEASE FORM

REQUEST FOR CANCELLATION OF GAP AGREEMENT