UNIVERSAL INSURANCE CANCELLATION REQUEST

1

WHO IS SUBMITTING THIS CANCELLATION* This field is required.Must be at least one name listed on the title

2

Main Customer Contact Email* This field is required.

example@example.com

3

STATUS OF LOAN* This field is required.

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

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

6

POLICY HOLDER NAME* This field is required.Who's Name Is First On The Title?

7

YEAR AND MAKE OF VEHICLE* This field is required.

If multiple vehicles are involved, please issue cancellation request separately

8

VIN NUMBER* This field is required.

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

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

11

PLEASE DESCRIBE REASON OF PRODUCT CANCELLATION(S)

12

NAME OF LOAN COMPANY

13

COMMENTS / ADDITIONAL INFORMATION

14

UPLOAD PROOF OF PAID-OFF LOAN AND THE ODOMETER STATEMENTWe 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

Can also be accepted in seperate email

15

SIGNATURE OF CUSTOMER REQUESTING CANCELLATION* This field is required.

Powered by Jotform SignClear

16

SIGNATURE OF DEALER EMPLOYEE REQUESTING CANCELLATION* This field is required.

Powered by Jotform SignClear