By entering your name, I am requesting that you please cancel my contract on the above-identified vehicle effective on the cancellation date listed above. I understand that once canceled coverage may not be repurchased or reinstated. I further understand that a cancellation fee may apply after 30 days. Final Submission of this application requires your signature at the dealership as well as millage verification. Please allow 30 days for the refund to be posted to your account; if you paid cash, you will receive a check in the mail.
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