Insurance Mileage Verification Form

Insurance Mileage Verification Form

Use this form to verify the insured vehicle's mileage for underwriting, premium calculation, or claims adjustment. Provide complete and accurate information. False statements may subject the signer to civil or criminal penalties.

Insured / Applicant Information

Policy Information

Personal Auto    Commercial Auto    Telemetry / Usage-Based    Other

Vehicle Information

Mileage Verification Method and Documentation

Indicate documentation provided to substantiate mileage (attach copies where applicable):

Odometer photograph(s) attached    Maintenance / service records    Dealer or independent inspection report

Lease / rental agreement showing mileage    Telematics / device report    Official registration / DMV record

Odometer Disclosure and Attestation

The undersigned certifies under penalty of perjury that the odometer reading reported below reflects the actual mileage of the vehicle described above to the best of the undersigned's knowledge and belief, except for the following indicated condition(s):

Odometer now reads on the date .

Check one:    The mileage stated reflects the actual mileage.    The odometer reading is not the actual mileage.    The mileage is unknown.

Exclusions, Audits, and Fraud Warning

This verification is limited to the representations made herein and the documents provided. The insurer reserves the right to request additional documentation, conduct an inspection, or obtain independent records to verify mileage. Any misrepresentation, omission, or falsification of mileage may result in premium adjustment, denial of a claim, cancellation or rescission of coverage, and civil or criminal penalties under applicable law.

By signing this form the insured authorizes the insurer and its representatives to obtain vehicle history, registration, service, or telematics data relevant to mileage verification from third parties, and to retain copies of submitted documentation for underwriting and audit purposes.

Beneficiary Information (if applicable)

Beneficiary Name

Relationship to Insured

Allocation Percentage

Declaration and Signature

I certify that I am the insured or an authorized representative of the insured and that the information contained on this form and in any attachments is true, correct and complete to the best of my knowledge. I understand that the insurer relies on this information for underwriting and premium determination. I acknowledge that knowingly providing false or misleading information may subject me to penalties under applicable law.

I consent to the release of vehicle mileage and related records to the insurer and authorize third parties to provide such records upon request to facilitate verification.

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