Transcription of GAP CANCELLATION REQUEST FORM - RpmOne
1 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.
2 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. Refund amount due to the 3 Step 4 Dealer pays the customer the refund amount indicated on the CANCELLATION CANCELLATION ProceduresDealer is responsible for refunding the customer the customer's GAP waiver purchase price as calculated by the above 2 Administrator sends refund check directly to dealer. Check is made payable to the dealership. Includes CANCELLATION Statement with the following information:Administrator calculates refund amount based on the original purchase refund amount is calculated as follows: Within 60 Days Full Refund $50 CANCELLATION fee After 60 Days Rule of 78 $50 CANCELLATION fee* (depending on state regulations)Amount refunded to dealer is for the dealer's cost of the GAP 1 Dealer faxes or emails the following documentation to RpmOne : Complete CANCELLATION form Copy of customer's GAP waiver contractHub Fax and Email Information:*Applies to refundable waivers only.
