Cancel a Claim

Contract Number
Customer Information
Buyer Name   
Street   
City, State, Zipcode   
Home Phone      
Cell Phone      
Email Address   
Co-Buyer Name   
Street   
City, State, Zipcode   
Home Phone      
Cell Phone   
Email Address   
 
Vehicle Information
VIN Number
Year
Make
Model
Trim
Dealer/Creditor Information
Dealer Name   
Phone      
Street   
City, State, Zipcode   
Lienholder Information
Name   
Phone      
Street   
City, State, Zipcode   
Reason For Cancellation
Buyer Request      Lienholder Request
Total Loss Vehicle Sold/Traded
Explanation Of Reason   
Date Recieved By Dealer/Creditor   
Date Of Repossession      
Date Of Other   
Odometer   
Cancellation Effective Date   

In consideration of this cancellation, I do hereby release and forever discharge the Administrator, Provider, and Lienholder, and I agree to hold the Administrator, Provider, and Lienholder harmless from any and all claims, demands, actions and payments arising from or related to the Contract, except for refund or partial refund of the Contract Purchase Price, if any. I understand that claims and administrative and cancellations fees set forth in the

Contract may be subtracted from any refund to which I may otherwise be entitled. I understand any Refund due will be paid to the Lienholder in the event the loan has not been satisfied, and that I must notify the Administrator within thirty (30) days if the refund has not been received by me or credited to the Lienholder.
I understand that I may be required to submit additional documentation to the Administrator or Provider in order to complete the Cancellation Process.

The information I provided will provide is true and accurate to the best of my knowledge.