APC/DAC Cancellation Request

And Warranty Liability Release Form

Click here to print this page

*Fill out before printing for signatures, or print blank copy.

Section I

Owner/Dealer Information
Vehicle Owners Name:
Dealer Name:
Street Address:
Street Address:
City:

State:

Zip:

City:

State:

Zip:

Section II

Vehicle Information
Vehicle Make:
Model: Year:
VIN:
Retail purchase price of the
Warranty to the Vehicle Owner:                   $

Section III
Warranty Cancellation / Release

Information
Warranty Registration Number:

Check this box if the cancellation is due by the customers request - THE CUSTOMER
                 MUST SIGN THIS FORM.
Warranty Registration Effective Date:

Check this box if the sale of the vehicle was not completed - Attach all copies of warranty and
the dealer MUST sign this form.
Warranty Cancellation Date:

Check this box if the cancellation is requested by the lender.  A copy of the lenders letter
requesting cancellation MUST be attached.

1.

With the completion and submission of this form the warranty benefit provided in the warranty identified by the Warranty Registration Number above will be cancelled and the vehicle owners right to make any claim against this warranty will be terminated.
2.

I understand that any refund due as a result of this cancellation will be subject to the CANCELLATION provisions provided for in the warranty.

REQUEST FOR CANCELLATION AND LIABILITY RELEASE SIGNATURES

I have read and fully understand all of the information on this form.  I understand that ALL of the warranty benefits provided for in the named warranty will be terminated and I release all securing parties from any and all liabilities relating to this warranty.

X______________________________

 ___________  

X____________________________

 ___________

Vehicle Owners Signature

        Date  

Vehicle Co-Owners Signature

Date
 

X______________________________

 ___________  

X________________________________________

Dealer Representative Signature

Date

  

Printed Name of Dealer Representative
 

NOTICE TO VEHICLE OWNER AND DEALER:  All of the information and documents requested on this form must be completed and provided before the cancellation can be processed.  Incomplete submissions will delay the processing of the cancellation and the refund.                                                     Click here to print this page