autotech protect cancellation form
DESCRIPTION
ÂTRANSCRIPT
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