Sens-O-Lock | Removal of Loss Protection Form | New York Ignition Interlocks | New York Ignition Interlock Device | New York Ignition Interlock Provider

Removal of Loss Protection Form

Please complete and sign this form. If you have any questions, you may contact us.

Removal of Loss Protection Authorization*
- I have requested that Loss Protection be removed from my existing lease agreement with Sens-O-Lock of America and agree to the terms listed below.
In the event that the Equipment is lost, stolen or damaged in an accident, the Lessee shall pay the sum of $1,995.00 to replace the equipment or necessary repair fees and shall continue to make the monthly payments due as itemized in the original lease agreement.

The loss protection removal will become effective upon my next payment date after the return of this signed Addendum C.
Customer Signature*
Date*
MM slash DD slash YYYY
Customer Printed Name*
Email*
Phone*
Consent*
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