GAP CANCELLATION REQUEST FORM

Dealer/Lender NamePolicy NumberBorrower/Member/Lessee NameCity/StateVehicle Year/Make/ModelVINLoan/Lease Origination DateDate of CancellationCompleted By: Trade-In Fully Paid Loan Totaled/StolenSignature of Authorized PartyDateFOROFFICEUSEE nrollment Number:Amount Refunded:ONLYDate Entered:Date Mailed:Date Received:Refund Due:Yes NoPLEASE PROMPLTY SUBMIT THIS REQUEST VIA FACSIMILE TOHUB/ Impact Insurance Services ATTN: GAP CANCELLATION 877-483-9983 GAP CANCELLATION REQUEST FORMYou, the member/borrower/lessee understands that the Guaranteed Auto Protection Enrollment will be cancelled. You must also understand that in the event the above referenced vehicle is stolen and un-recovered, or is deemed a total loss and your primary insurance company pays less than the amount of the installment sales contract/loan/lease, you will be fully responsible for any deficiency balance. Customer REQUEST Repossession(Attach Lienholder REQUEST )Reason for CANCELLATION (If applicable, please include the required document noted below with this form ): OR EMAIL: Fax:(877) 483 9983 Attention: Gap CANCELLATION Email: Amount refunded to the dealer.

• Fax: (877) 483‐9983 ‐ Attention: Gap Cancellation • Email: powersports@hubinternational.com • Amount refunded to the dealer. • …

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