Cancellation Request Form
Cancellation Request Form
CANCELLATION REQUESTS MUST BE PROCESSED THROUGH THE DEALERSHIP
Return document to: Allstate Dealer Services, 1776 American Heritage Life Dr., Bldg. B., Jacksonville, FL 32224, Attn: Cancellation Dept. Phone: 800-621-4871 Fax: 866-398-9021 Email: cancellations@
SECTION A ? PRODUCT TO BE CANCELLED (Select One)
Vehicle Service Contract (VSC) Tire & Wheel (TW) Complete Protection (CP) Theft Deterrent (TD) (except FP1554) Vehicle Appearance Prot. (VAP)
Guaranteed Asset Protection (GAP)* Excess Wear & Tear (EWT)* Roadside Services (RS)
Contract Number:
NOTICE REGARDING GAP CANCELLATION: THE CONSUMER HAS THE UNCONDITIONAL RIGHT TO CANCEL GAP FOR A FULL REFUND OR CREDIT WITHIN THIRTY (30) DAYS AFTER IT IS PURCHASED, PROVIDED THE COLLATERAL HAS NOT SUFFERED A TOTAL LOSS, AND THIS FORM, OR OTHER WRITTEN NOTICE OF CANCELLATION IS COMPLETED AND RETURNED TO THE ABOVE ADDRESS POSTMARKED NO LATER THAN THIRTY (30) DAYS AFTER THE GAP WAS PURCHASED. IF THE CONSUMER DOES NOT RECEIVE THE REFUND OR CREDIT WITHIN SIXTY (60) DAYS OF NOTICE OF CANCELLATION OR TERMINATION, THEY MAY CONTACT THE GAP ADMINISTRATOR.
SECTION B ? PRODUCER INFORMATION (Please PRINT)
___________________________________________________
Producer Name
Producer ID
Cancellation Effective Date (mm/dd/yyyy)
__________________________________________________________________________________________________________
Address
____________________________________ ____________________________________ ___________________________
City
State
Zip Code
___________________________________________________
Phone
___________________________________________________
Fax
SECTION C ? CUSTOMER INFORMATION (Please PRINT)
___________________________________________________
Last Name
___________________________________________________
Vehicle Identification Number (VIN)
___________________________________________________
First Name
___________________________________________________
Odometer Reading as of Cancellation Date
SECTION D ? 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
Total Loss ? Attach proof of total loss
Repossession - Attach proof of repossession
Other, please explain _________________________________________________
(Please include any supporting documentation)
*If canceling GAP or EWT, will a claim be filed?
Yes No
SECTION E - SIGNATURES
__________________________________________________ Dealership Personnel Signature
__________________________________________________ Customer Signature (If required, see Section D above)
____________________________________________________ Print Name
____________________________________________________ Today's Date (mm/dd/yyyy)
FP1663
Call for Cancellation Quote 800-621-4871
02/19
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