Product Cancellation Form
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Personal Information
First Name
Last Name
Email
Cell Phone
Home Address
City
State
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AL
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AR
CA
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DE
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PA
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SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Products to Cancel
Dealership Where Purchased
Select Store
Arlington Acura
Arlington Kia
Arlington Lexus
Arlington Nissan
Chesterton Nissan
Fort Wayne Acura
Fort Wayne Lexus
Fort Wayne Nissan/Infiniti
Fort Wayne Subaru
Fort Wayne Toyota
Fort Wayne KIA
Gurnee Hyundai
Gurnee VW
Indy Honda
Indy Hyundai
Kenosha Nissan
Lafayette Honda
Lafayette Hyundai
Lafayette Subaru
Lafayette Toyota
Lafayette KIA
Oakbrook Toyota
Schaumburg Ford
Schaumburg Honda
Schaumburg KIA
Schaumburg Lincoln
Admin Test
Products to Cancel
Select Product
Vehicle Service Contract
ValueShield
Guaranteed Asset Protection (GAP)
Excess Wear and Tear
Bundled Protections
Stand Alone Ancillary Protections
Do you have another product to cancel?
Choose
No
Yes
Products to Cancel
Select Product
Vehicle Service Contract
ValueShield
Guaranteed Asset Protection (GAP)
Excess Wear and Tear
Bundled Protections
Stand Alone Ancillary Protections
Do you have another product to cancel?
Choose
No
Yes
Products to Cancel
Select Product
Vehicle Service Contract
ValueShield
Guaranteed Asset Protection (GAP)
Excess Wear and Tear
Bundled Protections
Stand Alone Ancillary Protections
Do you have another product to cancel?
Choose
No
Yes
Products to Cancel
Select Product
Vehicle Service Contract
ValueShield
Guaranteed Asset Protection (GAP)
Excess Wear and Tear
Bundled Protections
Stand Alone Ancillary Protections
Vehicle Service Contract
Choose
AAGI
AAGI Wheelz
Certified Car Care
Highline
Manufactures Extended VSC
Smart Tech Pro
Type Product Name
Guaranteed Asset Protection
Choose
AAGI Gap Waiver
Old Republic Gap Waiver
Manufactures GAP Waiver
Type Product Name
Bundled Protections
Choose
Smart Driver
Driver Care
Stand Alone Ancillary Protections
Choose
Smart Driver Tire and Wheel (Only)
Smart Driver Key Replacement (Only)
Windshield Plus
Pivotal Finishes
Vehicle Information
Year
Make
Model
VIN
Mileage
Upload photo of odometer
Contract Purchase Date
Date of Cancellation
Reason for Cancellation
Original Purchase Type
Cash
Finance
Lease
Has the Vehicle been paid off?
Choose
No
Yes
Lien Holder/Bank (Optional, please provide if you have it)
Account Number (Optional, please provide if you have it)
If you are canceling the warranty or product because you have traded in or sold your vehicle, please provide us with a copy of the trade-in odometer statement you obtained from the dealer or a bill of sale. Without proof of payoff for any cancellation, we are required to send all refunds to the original lien holder.
Proof of Payoff
Disclosure Agreement
Upon accepting this disclosure agreement, you understand that you are now accepting all liability for any items that would otherwise be covered by the products you are canceling. The Rohrman Auto Group will NOT be liable for any repair costs or losses from the date of cancellation.
By signing this Electronic Agreement, you acknowledge that you have read, understand, and agree to the Disclosure Agreement. You certify you are legally able to execute the cancellation of these products. Please allow
up to 60 days
for the cancellation to be processed and for the funds to be received.
I certify that I approve this cancellation and agree with the disclosure agreement
Yes
Additional Notes
Full Name
Signature
❌
Date
Submit