GAP Insurance Form

1
Your Information
2
Check Your Eligibility
3
Declaration and
Consent
4
Review and Sign
First Name *
Last Name *
Email *
Phone *
Street Address
City
State/Region/Province
Country

GAP Insurance Form

1
Your Information
2
Check Your Eligibility
3
Declaration and
Consent
4
Review and Sign
Did you purchase GAP insurance when you bought or financed your vehicle? *
Do you remember how the GAP insurance was sold — for example, was it added by the dealership or finance company at the same time as your vehicle purchase? *
Were you clearly told that GAP insurance was optional and that you could buy it elsewhere, possibly at a lower cost? *

GAP Insurance Form

1
Your Information
2
Check Your Eligibility
3
Declaration &
Consent
4
Review and Sign
Additional Information

Please provide any other information you feel is relevant to your purchase or experience of GAP insurance.

GAP Insurance Form

1
Your Information
2
Check Eligibility
3
Declaration &
Consent
4
Review & Sign
Signature
Our Agreement With You (PLEASE SCROLL AND READ THE COMPLETE DOCUMENT TO ACKNOWLEDGE)
I acknowledge and agree that by electronically signing this document, I accept and consent to be bound by the terms and conditions of the Retainer Agreement set out above. I further acknowledge and consent that my electronic signature, together with the information I have supplied in this application, will be used to generate a completed Retainer Pack in my name, and that an executed copy of the Retainer Pack will be delivered to me at the email address I have provided. I also confirm that I have carefully read and fully understood the terms and conditions set out in the Retainer Agreement.

Form Summary

Your Information
Name *
Email *
Phone *
Address
Check Your Eligibility
Do you remember how the GAP insurance was sold — for example, was it added by the dealership or finance company at the same time as your vehicle purchase? *
How was GAP insurance sold? *
Were you clearly told that GAP insurance was optional and that you could buy it elsewhere, possibly at a lower cost? *
Declaration and Consent
Type here...
I confirm the information I’ve provided is true and accurate to the best of my knowledge. *
I consent to my data being used to review the sale of my GAP insurance and, where appropriate, to assist with raising a formal complaint or claim. *
Review and Sign
Signature
I acknowledge and agree that *