GAP CANCELLATION REQUEST FORM
Dealer/Lender Name
Policy Number
Borrower/Member/Lessee Name
City/State
Vehicle Year/Make/Model
VIN
Loan/Lease Origination Date Date of Cancellation
□Customer Request
Completed By:
□Trade-In
□Fully Paid Loan
□Totaled/Stolen
□
Repossession (Attach Lienholder Request)
Reason for Cancellation (If applicable, please include the required document noted below with this form):
Signature of Authorized Party
Date
PLEASE PROMPLTY SUBMIT THIS REQUEST VIA FACSIMILE TO
HUB/ Impact Insurance Services ATTN: GAP CANCELLATION 877-483-9983 OR EMAIL:
[email protected]
You, the member/borrower/lessee understands that the Guaranteed Auto Protection Enrollment will be cancelled. You must also understand that in the event the above referenced vehicle is stolen and un-recovered, or is deemed a total loss and your primary insurance company pays less than the amount of the installment sales contract/loan/lease, you will be fully responsible for any deficiency balance.
FOR OFFICE USE ONLY
Date Received:
Refund Due:
Enrollment Number:
Amount Refunded:
Date Entered:
Date Mailed:
Yes
No
GAP Cancellation Procedures Step 1
Dealer faxes or emails the following documentation to RpmOne: • Complete cancellation form • Copy of customer's GAP waiver contract Hub Fax and Email Information: • Fax: (877) 483‐9983 ‐ Attention: Gap Cancellation • Email:
[email protected]
Step 2
Administrator calculates refund amount based on the original purchase date. The refund amount is calculated as follows: • Within 60 Days ‐ Full Refund ‐ $50 cancellation fee • After 60 Days ‐ Rule of 78 ‐ $50 cancellation fee* (depending on state regulations) Amount refunded to dealer is for the dealer's cost of the GAP waiver. Dealer is responsible for refunding the customer the customer's GAP waiver purchase price as calculated by the above guidelines.
Step 3
Step 4
Administrator sends refund check directly to dealer. • Check is made payable to the dealership. • Includes Cancellation Statement with the following information: • Amount refunded to the dealer. • Refund amount due to the consumer. Dealer pays the customer the refund amount indicated on the Cancellation Statement. *Applies to refundable waivers only.
