AUTO INSURANCE VERIFICATION
I, ___________________________________, authorize my insurance agent/company
to disclose the following information to ___________________________________ for
the purpose of __________________________________.
Signature __________________________________ Date ______________________
Print Name __________________________________
INSURANCE AGENT: Please fill out and return to:
Fax Number _______________________ or E-Mail _______________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
THIS AREA TO BE COMPLETED BY THE INSURANCE AGENT
Insured Individual’s Name: ___________________________________
Address: ______________________________________________________________
City: ______________________________ State: ________________ Zip: __________
Insurance Company: ____________________________ Phone: __________________
Agent Contact Name: ____________________________ Fax: ___________________
Policy Start Date: ___________________ Policy End Date: ___________________
Is there liability for injuries or damage to a third (3
rd
) party? ☐ Yes ☐ No
Does the coverage cover the insured individual in an accident? ☐ Yes ☐ No
Does the coverage pay for damage done to rental vehicles? ☐ Yes ☐ No
Policy Number: _____________________ Expiration: ________________
Agent’s Signature __________________________________
Date ______________________
