(Dealership personnel may obtain a cancellation quote at ...

GENERAL INFORMATION

DEALERSHIP NAME

ADDRESS

CITY

ST

PHONE

PURCHASER'S NAME

VSC / GAP CANCELLATION REQUEST

P.O. Box 1049 Bedford, TX 76095 Fax: 800-349-1668

ADDRESS

ZIP

CITY

ST

ZIP

PHONE

CONTRACT INFORMATION

CONTRACT # (INCLUDE VSC AND GAP IF APPLICABLE)

LIENHOLDER NAME

LIENHOLDER CITY, ST ZIP

VIN LIENHOLDER ADDRESS LOAN ACCOUNT #

TERMINATION DETAILS (Dealership personnel may obtain a cancellation quote at .)

CANCELLATION DATE:

CANCELLATION ODO:

CANCEL PRODUCT:

VSC GAP

REFUND TO*:

LIENHOLDER CONTRACT HOLDER

REASON FOR TERMINATION (please select one)

CUSTOMER REQUEST / TRADE IN / SOLD REPOSSESSION UNWIND TOTAL LOSS OTHER

Colorado GAP Consumers: The Purchaser executed the application to purchase a Guaranteed Asset Protection Contract from the Colorado auto dealer/financial institution identified above. Pursuant to Rule 8 of the Colorado Uniform Consumer Credit Code (UCCC), the Purchaser has the unconditional right to cancel the GAP Contract for a full refund within thirty (30) days of purchase. The Purchaser must complete and return this form or send any other written notice of cancellation to Warranty Solutions, P.O. Box 1049, Bedford, TX 76095 postmarked no later than thirty (30) days after GAP was purchased. Cancellation refunds will be sent to the lienholder/lessor unless the Purchaser can provide proof that the GAP Contract Fee was not financed or was paid separately.

I request the above listed contract(s) be terminated. I certify I have no claims pending. I acknowledge receipt of the amount refunded, or if the contract price was financed as part of my vehicle purchase, I acknowledge the refundable amount will be made to the financing source.

Purchaser Signature

/

/

Date

Dealer Representative

*In all states but Florida, VSC cancellation refunds will be paid by the issuing dealership to the lienholder or contract holder.

(VSC Only) In Florida, Warranty Solutions will refund directly to the payee, specified in the "REFUND TO" section above. If the lienholder information is not provided in full, the refund will be made to the contract holder.

Please fax completed form to 800-349-1668.

D09WE555-03 (0519) Vehicle Service Contracts issued by WS Aftermarket Services Corporation and administered by Warranty Solutions Management Corporation. In Florida, Wisconsin, Arizona and Alaska, issued and administered by Warranty Solutions Administrative Services, Inc. (Florida License #60079). Also issued by Heritage Mechanical Breakdown Corporation in Florida (Florida License #60072). All contracts insured by Heritage Indemnity Company (CA C of A #08549), P.O. Box 1049, Bedford, TX 76095.

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