New York Ancillary Product Cancellation

Submitting this form starts a cancellation review. It does not guarantee that a product is cancellable or that a refund is due. Eligibility is governed by the product agreement and applicable law.

CUSTOMER INFORMATION

First Name *

Last Name *

Email *

Mobile Phone *

VEHICLE AND CONTRACT INFORMATION

VIN *

Stock Number

Vehicle Year *

Make *

Model *

Current Mileage *

Purchase Date

Finance Company / Lender

Loan or Contract Number

PRODUCTS REQUESTED FOR CANCELLATION

Vehicle Service Agreement (VSA)

Tire & Wheel Protection

Complete Care

Dent Protection

Theft Protection

GAP Protection

Multi Shield

Key Replacement

Windshield Protection

Other Product

Other Product of Contract Number

Reason for Cancellation *

CUSTOMER AUTHORIZATION

I certify that I am the purchaser or authorized owner. I authorize the dealership and product administrator to review this request. Any refund may be prorated and may be sent directly to the lender if a balance remains.

I electronically authorize submission of this cancellation request.

Electronic Signature *

Date *