Transcription of CANCELLATION REQUEST RETURN VIA FAX TO 870-508 …
1 CANCELLATION REQUEST RETURN VIA FAX TO 870-508 -6677 EMAIL Cancellations can be processed by submitting a copy of the service agreement with this form. Service Agreement Number: _____ Customer Name: _____ Vehicle Information Year: _____ Make: _____ Model: _____ VIN #: _____ CANCELLATION Date: _____ Mileage at CANCELLATION : _____ Reason for CANCELLATION *: _____ * Proof of total loss including cause of loss must be provided in order to process a total loss refund. Send Refund to: _____ _____ _____ _____ PLEASE NOTE THAT ALL CANCELLATION REQUESTS MUST BE NOTARIZED Signature: _____ Notary Public: _____ My Commission Expires: _____
