autotech protect cancellation form

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P.O. Box 2085 Dublin, Ohio 43017 Phone 855.807.2885 Effective 2/1/16 SERVICE CONTRACT REQUEST TO CANCEL ______Customer Request ______Another Party Request Contract Number: _________________________________ Name of Customer: ________________________________________________________ Name of non-customer making request (if applicable):____________________________ Year Make Model of Vehicle: ________________________________________________ Effective cancellation date requested:_______ Cancellation mileage________________ Is there a Lien Holder: Yes No If yes, name of Lien Holder:_______________________ Name of Dealership that sold the contract: ___________________________________________ Dealership Account Number:_______________________________________________________ CUSTOMER CANCELLATION REQUEST: A Customer may terminate (cancel) a Service Contract for any reason by providing the Selling Dealer with the Customer’s copy of the service contract and a written notice of the customer’s desire to terminate the contract. This form provides the required written notice. If there is a lien on the vehicle, the refund check will be made payable to the Customer and the lien holder. A cancellation fee will be charged to the customer as stated in the Service Contract. Reason for Cancellation (Please check appropriate box): _______ Traded or sold vehicle ____ Total loss of vehicle due to accident or theft ________Deal unwound ____ Repossession ________Customer request ____Other, please explain______________________________________________ Customer’s signature: ____________________________________________Date: _______ NON-CUSTOMER CANCELLATION REQUEST: Explain reason for request: _____________________________________________________ PAYEE INFORMATION: Payee on any refund: __________________________________________ Non-customer signature: _______________________________________Date: ____________ Submit this form to: American Colonial Administration, LLC Administrative Offices P.O. Box 2085 Dublin, Ohio 43017 Or fax to: 866.834.1740

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P.O. Box 2085 • Dublin, Ohio 43017 • Phone 855.807.2885

Effective 2/1/16

SERVICE CONTRACT REQUEST TO CANCEL

______Customer Request ______Another Party Request

Contract Number: _________________________________

Name of Customer: ________________________________________________________

Name of non-customer making request (if applicable):____________________________

Year Make Model of Vehicle: ________________________________________________

Effective cancellation date requested:_______ Cancellation mileage________________

Is there a Lien Holder: Yes No If yes, name of Lien Holder:_______________________

Name of Dealership that sold the contract: ___________________________________________

Dealership Account Number:_______________________________________________________ CUSTOMER CANCELLATION REQUEST: A Customer may terminate (cancel) a Service Contract for any reason by providing the Selling Dealer with the Customer’s copy of the service contract and a written notice of the customer’s desire to terminate the contract. This form provides the required written notice. If there is a lien on the vehicle, the refund check will be made payable to the Customer and the lien holder. A cancellation fee will be charged to the customer as stated in the Service Contract.

Reason for Cancellation (Please check appropriate box): _______ Traded or sold vehicle ____ Total loss of vehicle due to accident or theft

________Deal unwound ____ Repossession ________Customer request

____Other, please explain______________________________________________

Customer’s signature: ____________________________________________Date: _______

NON-CUSTOMER CANCELLATION REQUEST:

Explain reason for request: _____________________________________________________

PAYEE INFORMATION: Payee on any refund: __________________________________________

Non-customer signature: _______________________________________Date: ____________ Submit this form to: American Colonial Administration, LLC Administrative Offices P.O. Box 2085 Dublin, Ohio 43017 Or fax to: 866.834.1740