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Not all contacts are cancellable/refundable. See contract for

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Cancellation
Request Form
Submit all required documents with this form to:
Cancellation Department, P.O. Box 140249, Irving, Texas 75014-0249
Email: cancels@EGAssurance.com | Phone: 855-342-4971 | Fax: 214-996-0052
CXL-1705
Rev. 171103
© 2017 Ethos Group, Inc.
Not all contacts are cancellable/refundable. See contract for full terms and conditions.
The items below marked with an asterisk (*) are required to be completed in order to process the cancellation.
Customer
CUSTOMER’S NAME*
CO-CUSTOMER’S NAME
PHONE NUMBER
EMAIL ADDRESS
STREET ADDRESS*
CITY*
STATE*
ZIP*
Vehicle
YEAR
MAKE
MODEL
VIN*
Cancel Information
CANCELLATION ODOMETER*
REASON FOR CANCELLATION (SELECT ONLY ONE):
VEHICLE TRADED IN TOTAL LOSS LOAN PAID IN FULL
REPOSSESSION VEHICLE SOLD CUSTOMER DECIDED AGAINST
CANCELLATION DATE*
Refund Recipient
SELECT ONLY ONE AND COMPLETE THE ITEMS TO THE RIGHT OF THE SELECTED RECIPIENT. * Unless proof of Vehicle payoff is provided, the refund will be paid to the Lienholder.
REFUND TO LIENHOLDER
LIENHOLDER NAME
LOAN ACCOUNT NUMBER
STREET ADDRESS
CITY
STATE
ZIP
REFUND TO SELLER
YOU MUST PROVIDE A COPY OF:
Buyer’s Order or Odometer Statement
Proof of Payoff to Lienholder
Other Documentation May Be Requested by Cancellation Department
REFUND TO CUSTOMER
YOU MUST PROVIDE PROOF OF PAYOFF BY:
Copy of Lien Release, Clear Title Showing Lien Release, or Payoff Letter from Original Lender/Lessor
Other Documentation May Be Requested by Cancellation Department
Customer’s Signature*
Date*
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Completed 18 February 2021

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