Companion Care - Cancellation Form printable pdf download

Effective Date: 6/15/2015

Companion Care

Cancellation Form

Customer Request: __________________________

Another Party Request: _______________________

Circle type of cancellation:

Vehicle Service Contract

Service Plan

Contract Number: ___________________________

Name of Customer: __________________________________________

Name of Non-Customer Making Request (if applicable): ________________________________________

Year, Make & Model of Vehicle: ___________________________________________________________

Effective Cancellation Date Requested: ____________________________

Cancelation Mileage: _________________________

_______________________

If yes, Name of Lienholder: ___________________________________________________________

Is there a Lienholder:

Yes

Name of Dealership that Sold the Contract: __________________________________________________

Dealership Account Number: __________________

CUSTOMER CANCELLATION REQUEST: A Customer may terminate (cancel) a Vehicle Service Contract and/or Service Plan for any reason by

providing the Selling Dealer with the Customer’s copy of the Vehicle Service Contract and/or Service Plan and a written notice of the

customer’s desire to terminate the contract(s). 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

Vehicle Service Contract and Service Plan.

Reason For Cancelation:

(Please Check)

Appropriate Box)

______ Traded or Sold Vehicle

_______Total Loss of Vehicle due to Accident or Theft

______ Deal Unwind

_______ Repossession

______ Customer Request

Other, Please Explain: ______________________________________________________________________________________________

Customer Signature:

______________________________________________________________ Date: _______________________

Non- Customer Cancellation Request (Reason): __________________________________________________________________________

Payee Information

Payee on any Refund: _______________________________________________________________________________________________

Please submit this form to:

Consumer Service Corporation

PO Box 19340

Kalamazoo, MI 49019

855-996-7569

OR Fax to : 269-388-3554

Revised: 6/17/2015

Companion Care - Cancellation Form

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