Call for Cancellation Quote
FP1663 800-621-4871 02/19
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@allstatedealerservices.com
SECTION A
–
PRODUCT TO BE CANCELLED
(
Select One
)
Vehicle Service Contract
(
VSC
)
Guaranteed Asset Protection
(
GAP
)
*
Tire & Wheel
(
TW
)
Excess Wear & Tear
(
EWT
)
*
Complete Protection
(
CP
)
Roadside Services
(
RS
)
Theft Deterrent (TD) (except FP1554)
Vehicle Appearance Prot.
(
VAP
)
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 First Name
___________________________________________________ ___________________________________________________
Vehicle Identification Number (VIN) 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 Si
g
nature
____________________________________________________
Print Name
__________________________________________________
Customer Si
g
nature
(
If required, see Section D above
)
____________________________________________________
Toda
y
’s Date (mm/dd/yyyy)
PRINT FORM
SAVE FORM
CLEAR FORM
