This is a limited power of attorney which grants the insurer permission to complete the title paperwork for a specific vehicle on the owner's behalf. Used with both insured and claimants. Download File
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RELATED DOCUMENTS
Acknowledgment by the current owner that his vehicle has been declared a total loss, and that he/she has elected to retain the salvage for a specific sum of monies. Towing and storage charges are also specified.
POWER OF ATTORNEY TO TRANSFER MOTOR VEHICLE TYPE OR PRINT IN INK This is to certify that I, Print or Type Name of Owner of the County of and the State of Texas, owner of the following described motor vehicle, do make, constitute and appoint of the County of and the State of Texas, my true and lawful attorney, for me and in my name,...
Form 1190F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com DRIVERíS STATEMENT Driverís Name: Ownerís Name: Driverís Address: City: State: Age: Phone Nbr: Driverís License Nbr: State: EXP: // Employed By: Address of Employer: What was the vehicle being used for at time of accident? Date of Accident:...
Similar to Automobile Accident Report (1160F), this form is given to claimants to capture the details of an accident. Includes damages, occupants and witnesses.
Report form that is given to vehicle owners and drivers to capture the details of an accident. Includes occupants, injuries, damages and witnesses.
A sworn statement by a policyholder on an automobile claim. Filled out and notarized, this is a formal request by the insured for payment from the insurance company.
Used to determine a vehicle's value after a total loss by considering the book value and local market value (dealer quotes).
A loss report form filled out by insureds and/or agents when reporting an automobile accident. Includes information on occupants, injuries, damages and witnesses.
Form 1120F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com Claim Number Policy Number VEHICLE REPAIR ORDER I hereby authorize as my chosen repair facility to repair my vehicle, which is described below, and in accordance with the estimate which was prepared by the repair facility. Year: Make: Model:...
Automobile Loss Notice (Acord)
Digital Photo Sheet 2
Form 1110F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com SWORN STATEMENT IN PROOF OF LOSS (AUTOMOBILE) POLICY NUMBER CLAIM NUMBER to POLICY PERIOD INSURANCE COMPANY NAME By the above numbered policy of insurance, you insured (hereafter called the Insured) against damage or loss of to the automobile...
Form 1100F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com PASSENGERíS STATEMENT Name: Address: Occupation: Employed by: Age: Driving Experience: Date of accident: Hour Day or night? Location of accident: Vehicle Year, Make, and Model (that you were in): Was the vehicle in good operating order at...
Form 1090F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com VEHICLE INSPECTION REPORT Claim Number Agency Date of Accident Policy Number To: On , 20, I personally examined the vehicle below which was involved in an accident on . Identification and examination was made at . Owner: Owner Address: Year:...
Form 1080F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com VEHICLE - BILL OF SALE In consideration of the payment to me or on my behalf, the sum of Dollars ($) by the receipt of which is acknowledged, I hereby bargain, sell and convey the following vehicle to its new owner . Year: Type: Make: VIN: . I...
Form 1070F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com NOTICE OF SUBROGATION RIGHTS Claim Number: On , you or your vehicle was involved in an accident with, our policyholder. We have settled with our policyholder and now look to you for reimbursement of $. If you were covered by insurance, merely complete...
Form 1060F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com RELEASE AND TRUST AGREEMENT Uninsured / Underinsured Motorist Coverage PROPERTY DAMAGE ONLY I/we, for the sole consideration of dollars ($) to be paid by , hereinafter called the Company, the undersigned in his/her/their capacity as insured(s), and/or...
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