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Get GAP FP7209 2012-2024

GAP Cancellation Request Form Return document to American Heritage Insurance Services 1776 American Heritage Life Dr. CANCELLATION YOU HAVE THE UNCONDITIONAL RIGHT TO CANCEL GAP FOR A FULL REFUND/CREDIT WITHIN THIRTY 30 DAYS AFTER IT IS PURCHSASED PROVIDED YOUR COLLATERAL HAS NOT SUFFERED A TOTAL LOSS AND YOU COMPLETED AND RETURNED THIS FORM OR OTHER WRITTEN NOTICE OF CANCELLATION TO THE ABOVE ADDRESS POSTMARKED NO LATER THAN THIRTY 30 DAYS AFTER THE GAP WAS PURCHASED. IF YOU DO NOT RECEIVE THE REFUND/CREDIT WITHIN SIXTY 60 DAYS OF NOTICE OF CANCELLATION/TERMINATION CONTACT THE GAP ADMINISTRATOR. SECTION A - DEALER INFORMATION Please PRINT Account Name Today s Date mm/dd/yyyy Address City State Phone Zip Code Fax SECTION B - CUSTOMER INFORMATION Please PRINT Last Name Customer Contact Number First Name GAP Addendum Number VIN Number Last 6 Digits SECTION C REASON FOR CANCELLATION Please check one To process this cancellation request the following supporting documentation is required Customer Request - Attach correspondence or customer signature below Date Received by Dealer // Repossession - Attach proof of repossession from lienholder Other please explain Other Date Please include any supporting documentation SECTION D SIGNATURES // Dealership Personnel Signature Print Name Customer Signature If required see Section C above Cancellation Date Call for Cancellation Quote American Heritage Insurance Services 800-621-4871 FP7209 Rev. 04/12. Jacksonville FL 32224 Attn Cancellation Dept. Phone 800. 621. 4871 Fax 866. 398. 9021 email cancellations allstatedealerservices. com Please complete ALL sections of this form and submit along with a copy of a cancellation quote if one was received and the Guaranteed Asset Protection GAP Addendum Addendum. CANCELLATION YOU HAVE THE UNCONDITIONAL RIGHT TO CANCEL GAP FOR A FULL REFUND/CREDIT WITHIN THIRTY 30 DAYS AFTER IT IS PURCHSASED PROVIDED YOUR COLLATERAL HAS NOT SUFFERED A TOTAL LOSS AND YOU COMPLETED AND RETURNED THIS FORM OR OTHER WRITTEN NOTICE OF CANCELLATION TO THE ABOVE ADDRESS POSTMARKED NO LATER THAN THIRTY 30 DAYS AFTER THE GAP WAS PURCHASED. IF YOU DO NOT RECEIVE THE REFUND/CREDIT WITHIN SIXTY 60 DAYS OF NOTICE OF CANCELLATION/TERMINATION CONTACT THE GAP ADMINISTRATOR* SECTION A - DEALER INFORMATION Please PRINT Account Name Today s Date mm/dd/yyyy Address City State Phone Zip Code Fax SECTION B - CUSTOMER INFORMATION Please PRINT Last Name Customer Contact Number First Name GAP Addendum Number VIN Number Last 6 Digits SECTION C REASON FOR CANCELLATION Please check one To process this cancellation request the following supporting documentation is required Customer Request - Attach correspondence or customer signature below Date Received by Dealer // Repossession - Attach proof of repossession from lienholder Other please explain Other Date Please include any supporting documentation SECTION D SIGNATURES // Dealership Personnel Signature Print Name Customer Signature If required see Section C above Cancellation Date Call for Cancellation Quote American Heritage Insurance Services 800-621-4871 FP7209 Rev* 04/12. .

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