Mpp Cancel – Fill Out and Use This PDF

OLD UNITED CASUALTY CO.

P.O. Box 634

Shawnee Mission, Kansas 66201-0634

REQUEST TO CANCEL A GAP INSURANCE POLICY

ALL INFORMATION MUST BE FILLED OUT COMPLETELY AND LEGIBLY TO

PROCESS THIS CANCELLATION REQUEST.

ANY INFORMATION OMITTED MAY DELAY THE PROCESS.

CUSTOMER INFORMATION

Name

Address

City, State & Zip Code

Area Code/Phone Number

AUTO DESCRIPTION

Year, Make and Model

Last six digits of identification number

1Cancellation requests received on autos that are still secured by a lien must have the Lieholders name, address, account number and phone number included on this cancellation request form. ALL REFUNDS ON AUTOS THAT ARE STILL SECURED BY A LIEN WILL BE PAID DIRECTLY TO THE LIENHOLDER.

2Cancellation requests received on autos that have had the lien paid off or released must have attached proof of release of lien, copy of clear title or a lien release letter from lienholder. If not included, proceeds will go to lienholder.

PLAN NAME(S) TO BE CANCELLED

REASON FOR CANCELLATION (Please check one reason only)

If cancellation date is other than today’s date, documentation is required as follows:

■If your auto was traded or sold, attach a copy of the odometer statement.

■If a total loss occurs to your auto, and the cancellation date is prior to request date, attach a copy of the insurance loss report and record the mileage.

■If a respossession occurs, attach a copy of the lienholder’s request.

■Flat cancellatoin (full refund “if” cancellation is done within 30 days of purchase date and a claim has not been filed, a cancel- lation fee may apply).

We reserve the right to verify and document date and mileage. All refunds on autos that are still secured by a lien will be paid directly to the lienholder. For cancellation proeeds on clear liens, distribution of cancellation proceeds other than described herein must have separate, customer signature-endorsed instructions.