Vehicle Insurance Verification Form

Information you will need

• What's the name of the insurance company?
• What’s the policy number?
• What's the insurance company's phone number?
• THIRD PARTY ONLY: What’s your fax number?
• THIRD PARTY ONLY: What’s your e mail?
• AGENT ONLY: What’s the insured person’s name?
• What's the insured person's street address?
• In what city does the insured person live?
• In what state does the insured person live?
• What’s the insured person’s ZIP code?
• What’s your name?
• What’s your fax number?
• What’s the effective date of the insurance policy?
• Is there third party liability insurance?
• Does the policy cover the insured person?
• Are rental vehicles covered?
• What's your printed name?
• On what date does the policy expire?
• INSURED ONLY: What’s your name?
• INSURED ONLY: Who’s requiring verification?
• INSURED ONLY: Why is your insurance information needed?
• INSURED ONLY: What's your printed name?

Completed by the agent.

The form includes 2 signature lines.