CANCELLATION FORM - Squarespace · PDF filecancellation form. cancellation requested by ......

Click here to load reader

  • date post

    05-Jun-2018
  • Category

    Documents

  • view

    274
  • download

    13

Embed Size (px)

Transcript of CANCELLATION FORM - Squarespace · PDF filecancellation form. cancellation requested by ......

  • CANCELLATION FORM

    CANCELLATION REQUESTED BY (CHECK ONE)*: CONTRACT TYPE:

    CUSTOMER LIENHOLDER VEHICLE SERVICE GAP

    CONTRACT AND CANCELLATION INFORMATION

    DATE OF THIS REQUEST: CANCELLATION DATE REQUESTED*:

    CUSTOMER NAME*: CONTRACT NUMBER(S):

    CUSTOMER ADDRESS*:

    CITY*: STATE*: ZIP*:

    NAME OF PARTY MAKING REQUEST*:

    VEHICLE INFORMATION YEAR*: MAKE*: MODEL*:

    VIN*:

    ODOMETER READING AT REQUESTED CANCELLATION DATE*:

    IS THERE A LIENHOLDER?*: YES NO IF YES, NAME OF LIENHOLDER:

    LIENHOLDER ADDRESS:

    CITY: STATE: ZIP:

    NAME OF SELLING DEALERSHIP:

    REASON FOR CANCELLATION AND REQUIRED DOCUMENTATION

    CUSTOMER REQUEST (PLEASE EXPLAIN)____________________________________________________________________________ ATTACH ODOMETER STATEMENT^

    REPOSSESSIONATTACH LETTER OF REPOSSESSION

    TOTAL LOSSATTACH TOTAL LOSS REPORT

    OTHER _________________________________________________________________________________________________ ATTACH ODOMETER STATEMENT^

    ^ = An Odometer Statement can be any document that provides evidence of the mileage at the time of the cancellation request.

    SIGNATURE

    I hereby request cancellation of the Vehicle Service Contract/GAP Contract defined above. In consideration of such cancellation, I release and discharge Alpha Warranty Services from any and all liability with respect to this Vehicle Service Contract/GAP Contract. I further agree to hold Alpha Warranty Services harmless from any claims, actions, or payments. I represent I have authority to execute this request.

    CUSTOMER OR REQUESTING PARTY*:___________________________________________________ DATE: _______________________

    RETURN COMPLETED CANCELLATION FORMS TO:

    BY MAIL: ALPHA WARRANTY SERVICES PO BOX 580 RIVERTON, UT 84065

    BY FAX: 801.987.9998

    BY EMAIL: cancel@alphawarranty.com

    AWS-CF-4655 Rev. 10 APRIL 2016 Alpha Warranty Services, Inc Page 1 of 1

    A reason for cancellation must be selected. The requesting party must provide the appropriate paperwork listed after the selected reason.

    TRADE INATTACH ODOMETER STATEMENT^

    SOLD PRIVATELYATTACH ODOMETER STATEMENT^

    LIENHOLDER ACCOUNT NUMBER:

    (SIGNATURE)

    NAME:_______________________________________________(PRINT)

    REASON FOR CANCELLATION

    * = Mandatory Field

    DEALER

    mailto:cancel@alphawarranty.com

    Check Box15: Check Box16: Check Box18: Check Box19: Check Box20: Check Box21: Check Box26: Check Box27: Check Box22: Check Box23: Check Box24: Check Box25: Cxl Date: Cust Name: Cont #: Address: City: State: zip: Party name: year: Make: Model: VIN: Odometer read: Lienholder: Lien add: Lien city: Lien state: Lien zip: Selling dealer: Cust request: Other: Signature: Date: Sig date: Lienholder Account Number: Printed Name: Check Box1: