GAP Insurance Refund Request

Handle the cancellation and reimbursement of a vehicle GAP policy in a single document. It brings together dealer, customer and lender details, contract numbers, start and cancellation dates, the amount, the reason for cancelling and the supporting paperwork, closing with signatures from both sides. Insurers and dealerships cut down on email ping-pong.

Use this template

Complete every section so the GAP refund can be processed. Missing details will delay the outcome of your case.

Dealer name

Dealer email

Dealer contact person

Nombre

Apellido

Dealer phone number

Dealer fax number

Dealer address

Dirección

Ciudad

Estado / Provincia

Código postal

Customer name

Nombre

Apellido

Customer phone number

Customer mobile number

Customer email

Customer address

Dirección

Ciudad

Estado / Provincia

Código postal

Financial institution name

Financial institution email

Financial institution contact person

Nombre

Apellido

Financial institution phone number

Financial institution fax number

Financial institution address

Dirección

Ciudad

Estado / Provincia

Código postal

Finance contract number

GAP contract number

Date of effectivity

Date of cancellation or expiration

Term of contract

Attach the GAP addendum here

Max 10 MB per file

State the reason for the cancellation and attach the paperwork that supports it.

Reason for cancellation

Vehicle sold Vehicle traded in Loan paid off early Total loss Loan refinanced Cancelled within the cooling-off period

Supporting document 1

Max 10 MB per file

I declare that the information provided is correct and request the refund of the unused portion of the GAP premium.

Customer signature

Sign here

Date signed by the customer

Dealer representative signature

Sign here

Date signed by the dealer representative

Internal use: the refund amount is calculated pro rata from the cancellation date, less any applicable fees.

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