Warranty Cancellation Form
Customer Information
First Name
Last Name
Email
Phone
Address
City
State
Select state
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Vehicle Information
Year
Make
Select make
Acura
Audi
BMW
Buick
Cadillac
Chevrolet
Chrysler
Dodge
Ford
GMC
Honda
Hyundai
Infiniti
Jeep
Kia
Lexus
Mazda
Mercedes-Benz
Nissan
Ram
Subaru
Tesla
Toyota
Volkswagen
Volvo
Other
Model
Select model
VIN
VIN is captured as typed for accuracy.
Odometer (at cancellation)
Select range
0 - 10,000
10,001 - 20,000
20,001 - 30,000
30,001 - 40,000
40,001 - 50,000
50,001 - 60,000
60,001 - 75,000
75,001 - 100,000
100,001 - 125,000
125,001 - 150,000
150,001 - 200,000
200,001+
Contract Details
Product Type
Select product
Vehicle Service Contract
GAP
Maintenance
Tire & Wheel
Paint / Fabric
Windshield
Theft / Etch
Key Replacement
Other
Provider
Select provider
IA
Toyota
GSFS
NSD
Endurance
Capital
Allstate
Fortegra
Other
Contract Number
Cancellation Reason
Select reason
Traded
Sold Outright
Total Loss
Changed Mind
Refinanced
Other
Specify Other Reason
Refund Payee
Select payee
Customer
Lienholder
Dealer
Lienholder (type exact name)
If a lien existed, enter the lender’s exact name.
Lien Release (PDF/JPG/PNG)
Required if Refund Payee is Customer and a lienholder is listed.
Odometer Proof (dated photo or document)
Upload a dated photo/document showing current mileage.
Reset
Submit Cancellation
Submission Instructions
• If Refund Payee is Customer and there was a lien, you must upload the lien release.
• Upload a dated odometer photo or document for mileage verification.
• Ensure provider and reason are selected accurately to avoid delays.
Request submitted
Your cancellation was submitted successfully.
OK