Fillable Vehicle Service Contract Cancellation Request

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Vehicle Service Contract Cancellation Request

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The Vehicle Service Contract Cancellation Request form is 1 page long and contains:

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VSCCxl201707
Vehicle Service Contract Cancellation Request
CUSTOMER INFORMATION
Customer Name: _________________________ Co-Customer Name: ______________________
Customer address: _____________________________________________________________________
Street Address City, State, Zip
VEHICLE/CONTRACT INFORMATION
Contract №: ____________________________ VIN: __________________________________
Cancellation Date: ________________________ Cancellation Mileage: _____________________
Cancellation Reason:
I/We attest the above cancellation mileage is accurate at the time of cancellation. I/We fully understand
the vehicle service contract will no longer provide any benefits from this date forward and any cancellation
refund due will be processed within 30 days of SilverRock’s receipt of this completed request form. I/We
understand a cancel fee may apply and I/we may refer to the contract for more details.
___________________________________
Customer Signature
______________________
Date
___________________________________
Co-Customer Signature
______________________
Date
Please submit completed, signed form to SilverRock by mail, fax, or email:
By Mail:
SilverRock Automotive, Inc.
P.O. Box 29087
Phoenix, AZ 85038-9087
By Fax:
866-837-8258
By Email:
cancellations@silverrockinc.com
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Vehicle Service Contract Cancellation Request

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Completed 31 January 2022

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