Transcription of GAP CANCELLATION REQUEST FORM
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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.
Dealer/Lender Name Policy Number Borrower/Member/Lessee Name City/State Vehicle Year/Make/Model VIN Loan/Lease Origination Date Date of Cancellation Completed By:
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