Gap Insurance Refund Form

Gap Insurance Refund Form
Please complete all the fields below and submit attached your copy of the Guaranteed Asset Protection Addendum.
Dealer Information
Dealer Name
Email
example@example.com
Name of Contact
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Customer Information
Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Financial Institution
Financial Institution Name
Email
example@example.com
Name of Contact
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Vehicle Information
Contract Number
Contract Number
Date of Effectivity
MonthDayYear
Date
Date of Cancellation/Expiration
MonthDayYear
Date
Contract Amount
Term of Contract
Attach GAP Addendum here
Cancelof
Cancellation Information
For the following options, please provide/attach the necessary:
- PAID-OFF LOAN
  Provide a copy of proof of payoff from the lienholder.
- REFINANCING
  Provide a copy of proof of refinancing with new lienholder and the proof of payoff from lienholder on the original or former contract
- REPOSSESSION
  Repossession letter from the lienholder
- CUSTOMER TRADED/SOLD/RETURNED COVERED VEHICLE
  Attach the Odometer statement with the signature of the contract holder
- RE-CONTRACT/FRAUD/LOAN NOT FUNDED
  Attach a proof of re-contract/fraud/loan not funded
- TOTAL LOSS
  Attach proof of loss date and proof of payoff from the lienholder
Purpose of Cancellation
Other
1
Cancelof
Attestation
I hereby request the cancellation of the GAP Program Addendum. In consideration of this cancellation, I do hereby release and forever discharge the Dealer/Creditor and I agree to hold the Financial Institution/Lender and Dealer/Creditor harmless from any and all claims, demands, action and payment on this Addendum, except for partial refund of the charge.
Signature of Customer
Clear
Date Signed by Customer
MonthDayYear
Date
Signature of Dealer Representative
Clear
Date Signed by Dealer Representative
MonthDayYear
Date
Please give at around three to four weeks processing of your request.
Thank you.
Should be Empty:

Gap Insurance Refund Form

Dealer Information

Customer Information

Financial Institution

Vehicle Information

Cancellation Information

Attestation