Product Cancellation Form

Personal Information

First Name

Last Name

Email

Cell Phone

Home Address

City

State

Zip

Products to Cancel

Dealership Where Purchased

Products to Cancel

Do you have another product to cancel?

Products to Cancel

Do you have another product to cancel?

Products to Cancel

Do you have another product to cancel?

Products to Cancel

Vehicle Service Contract

Type Product Name

Guaranteed Asset Protection

Type Product Name

Bundled Protections

Stand Alone Ancillary Protections

Vehicle Information

Year

Make

Model

VIN

Mileage

Upload photo of odometer

Contract Purchase Date

Date of Cancellation

Reason for Cancellation

Original Purchase Type

Has the Vehicle been paid off?

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