Mpp Cancellation Form – Fill Out and Use

Mechanical Protection Plan/ Old United

P.O. Box 634, Shawnee Mission, Ks. 66201‐0634

CANCELLATION REQUEST FORM

All information must be filled out completely and legibly to process this cancellation request

Any information omitted may delay the cancellation process. All cancellations will be processed within 30 days of receipt.

CUSTOMER INFORMATION

Name	______________________________________________________________________________
	Last	Middle Initial	First
Address	______________________________________________________________________________
City, State & Zip Code	______________________________________________________________________________
Area Code/Phone #	________________________ Email Address _____________________________________________
VEHICLE INFORMATION

LIENHOLDER INFORMATION

Is there a lien on the vehicle		Yes 1	No 2
Lienholder Name	_____________________________________ Account #________________________________________
Lienholder Address	____________________________________________________________________________________

1 Cancellation requests received on vehicles that are still secured by a lien must have the lienholders name, address, and account number included on this

cancellation request form. ALL REFUNDS ON VEHICLES THAT ARE STILL SECURED BY A LIEN WILL BE PAID DIRECTLY TO THE LIENHOLDER.

2 Cancellation requests received on vehicles that have had the lien paid off or released must have attached proof of release of lien, copy of clear title or lien release

letter from lienholder. IF NOT INCLUDED, ANY REFUND DUE WILL GO TO THE LIENHOLDER ON FILE.

Flat cancellation may be provided if cancellation is done within 30 days of purchase date and a claim has not been filed.

PLAN(S) TO BE CANCELLED

Please check all boxes that apply (boxes left blank will not be cancelled)

Club Plus	Platinum Plus	Mechanical Service Agreement	Maintenance	Lease Wear
Gap	OnGard	PDR (Paintless Dent Repair)	TireAssure	Credit Insurance

Other:__________________________________________________________________________________________________________________________________

Lojack, Skylink, Skyway, Theft guarantee cancellations can only be processed if the UNIT has not been installed and the cancel request MUST be received from the dealer. Zaktek is non‐cancelable.

REASON FOR CANCELLATION

Vehicle Traded In – (Include odometer statement)	Total Loss – (Need loss paperwork from insurance Company)	Customer Request
Sold Vehicle – (Include odometer statement or bill of sale)		Paid in Full – (include paid in full letter)

Other:__________________________________________________________________________________________________________________________________

Cancellation Mileage _____________________________________Cancellation Date ___________________________________(if other than today’s date see below)

We reserve the right to verify and document date and mileage. For cancellation refunds on clear liens, distribution of cancellation refunds other than described herein must have separate, customer signature‐endorsed instructions. Dealer signature only required on unwind or re‐contracted transactions.

Form sent in by	Customer	Dealer	Lienholder
Dealer Name	__________________________________________			Customer Name	______________________________________________________
Dealer Signature	__________________________________________			Customer Signature	______________________________________________________
Dealer Signature	__________________________________________			Date Signed	______________________________________________________

FOR DEALER USE ONLY

Vehicle Traded In & Refund to be sent to a participating MPP Dealer – (Include odometer statement) and customer must sign below.

Customer Signature: _____________________________________________________________

I release all rights to my refund amount

Dealer Name ___________________________________ Address ______________________________________________________

White – MPP Copy

Canary – Dealer Copy

Pink – Customer Copy