Auto Insurance Verification Letter Template



AUTO INSURANCE VERIFICATIONI, ___________________________________, 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 AGENTInsured 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 (3rd) party? ? Yes ? NoDoes the coverage cover the insured individual in an accident? ? Yes ? NoDoes the coverage pay for damage done to rental vehicles? ? Yes ? NoPolicy Number: _____________________ Expiration: ________________Agent’s Signature __________________________________ Date ______________________ ................
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