Automobile Insurance Motor Vehicle Inspection Report
Automobile Insurance Motor Vehicle Inspection Report
This report is for insurance underwriting purposes only.
The Alberta Superintendent of Insurance has approved this form pursuant to section 803 of the Insurance Act.
This report is required only if the vehicle is 12 years or older and must be completed by a Certified Automotive Technician.
Vehicle Owner's Name
Insurance Company
Insurance Broker
Policy Number
Vehicle Year
Make
Model
VIN
This section is to be completed by a Certified Automotive Technician.
Steering
Roadworthy Reject
Steering Box/Rack
Struts/Shocks
Front Suspension
Tie Rod Ends
Electrical System Roadworthy Reject
Head Lamp/Tail Lamps
Stop Lamps
Signal Lamps
Windshield Wipers
Tires
Roadworthy Reject
Front
Rear
Brakes
Roadworthy Reject
Front Lining or Drums
Rear Lining or Drums
Park
Brake Hoses
Brake Lines
General Conditions Roadworthy Reject
Body Condition
Muffler/Exhaust
Motor
Windshield
Seat Belts
Comments Comments Comments Comments
Comments
Is this vehicle roadworthy? Yes No Has the vehicle been altered for speed or performance? Yes No
Other Comments
Certified Automotive Technician Statement: I certify that I have inspected and tested the motor vehicle described above and found it to be in the condition stated above.
Name of Automobile Repair Shop
Address
City Certified Automotive Technician's Name
Province/Territory
AB
Postal Code
Telephone Number
Certified Automotive Technician's Certificate Number
Date (yyyy-mm-dd)
Certified Automotive Technician's Signature
FSRP11463 Rev. 2018-07
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