GAP Cancellation Request Form
Return document to: American Heritage Insurance Services, 1776 American Heritage Life Dr., Jacksonville, FL 32224
Attn: Cancellation Dept. Phone: 800.621.4871 Fax: 866.398.9021 email: cancellations@allstatedealerservices.com
Please complete ALL sections of this form and submit along with a copy of a cancellation quote, if one was received, and the Guaranteed Asset Protection (GAP) Addendum (Addendum).
CANCELLATION: YOU HAVE THE UNCONDITIONAL RIGHT TO CANCEL GAP FOR A FULL REFUND/CREDIT WITHIN THIRTY (30) DAYS AFTER IT IS PURCHSASED PROVIDED YOUR COLLATERAL HAS NOT SUFFERED A TOTAL LOSS, AND YOU COMPLETED AND RETURNED THIS FORM OR OTHER WRITTEN NOTICE OF CANCELLATION TO THE ABOVE ADDRESS POSTMARKED NO LATER THAN THIRTY (30) DAYS AFTER THE GAP WAS PURCHASED. IF YOU DO NOT RECEIVE THE REFUND/CREDIT WITHIN SIXTY (60) DAYS OF NOTICE OF CANCELLATION/TERMINATION, CONTACT THE GAP ADMINISTRATOR.
SECTION A - DEALER INFORMATION (Please PRINT)
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Account Name |
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Today’s Date (mm/dd/yyyy) |
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Phone |
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SECTION B - CUSTOMER INFORMATION (Please PRINT) |
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Last Name |
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First Name |
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Customer Contact Number |
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GAP Addendum Number |
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VIN Number(Last 6 Digits) |
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SECTION C – REASON FOR CANCELLATION (Please check one) |
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To process this cancellation request, the following supporting documentation is required: |
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Customer Request - Attach correspondence or customer signature below |
Date Received by Dealer ____/____/____ |
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Repossession - Attach proof of repossession from lienholder |
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Repossession Date |
____/____/____ |
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Other, please explain _________________________________________________ |
Other Date |
____/____/____ |
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(Please include any supporting documentation) |
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SECTION D – SIGNATURES |
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__________________________________________________ |
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____________________________________________________ |
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Dealership Personnel Signature |
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Print Name |
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__________________________________________________ |
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____________________________________________________ |
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Customer Signature (If required, see Section C above) |
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Cancellation Date |
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Call for Cancellation Quote:
American Heritage Insurance Services
800-621-4871