Insurance Vehicle Replacement Form

INSURANCE VEHICLE REPLACEMENT FORM

Use this form to request a replacement vehicle under your motor insurance policy when the insured vehicle is unavailable for repair, has been declared a total loss, or requires substitution under the terms of the policy. Complete every applicable field and attach supporting documentation listed in the Documentation Checklist. Submitting this form constitutes a written attestation under penalty of law that the information provided is true and complete to the best of your knowledge.

INSURED / APPLICANT INFORMATION

POLICY DETAILS

ORIGINAL VEHICLE DETAILS

Year:    Make:    Model:    VIN:

License Plate:    Registration State:    Ownership Status: Titled Leased Financed

REPLACEMENT VEHICLE DETAILS

Replacement Year:    Make:    Model:

VIN:    License Plate:

REPLACEMENT INFORMATION & LOSS DETAILS

Replacement/Loss Date:

Theft    Total loss / declared salvage    Voluntary sale / disposition    Mechanical failure    Purchase/upgrade    Other

COVERAGE SELECTION / CLAIM COVERAGE APPLICABLE

Indicate coverages that apply to this replacement request:

Collision    Comprehensive    Liability    Uninsured Motorist    Underinsured Motorist

Medical Payments    Rental Reimbursement    Roadside Assistance    Replacement Cost Coverage   Limit:

DOCUMENTATION CHECKLIST (attach copies)

Police report (if applicable)    Title / registration    Photographs of loss / vehicle   

Repair estimate / appraiser report    Proof of purchase / invoice    Salvage / disposition documents

EXCLUSIONS & ACKNOWLEDGMENT

The insurer's obligation to provide a replacement vehicle or pay replacement costs is governed by the terms, conditions and exclusions of the policy. Typical exclusions may include unreported modifications, use as a commercial or ride-share vehicle not covered by this policy, wear and tear, mechanical breakdown unrelated to covered loss, and losses caused intentionally by the insured. The insured must notify the insurer of any lienholder or secured party and provide required documentation; failure to disclose may delay or void coverage for replacement proceeds.

I acknowledge I have read and understand the exclusions above and certify that no material facts have been omitted.

BENEFICIARY DESIGNATION (IF APPLICABLE)

Name:    Relationship:    Percentage:

DECLARATION, AUTHORIZATION AND ASSIGNMENTS

I certify that the information provided in this Insurance Vehicle Replacement Form is true, complete and accurate. I understand that any misrepresentation, omission or false statement may result in denial of coverage and may subject me to civil or criminal penalties under applicable law. I authorize the insurer, its representatives and adjusters to obtain and inspect records, vehicle history, repair estimates, photographs, and other documents relevant to the replacement request. I agree to cooperate with inspections, appraisals, and salvage handling as required.

If the insurer elects to pay replacement proceeds, I understand payment will be subject to any valid lienholder interest and applicable policy deductible. I agree to assign to the insurer any recovery rights against responsible third parties for amounts paid under the policy, and I will execute documents necessary to effectuate subrogation or recovery. I further agree to repay any overpayment or undue payment made in error.

I authorize release of information contained in this form to any party with a reasonable need to investigate or process this replacement request, including but not limited to appraisers, repair facilities, and lienholders.

ADDITIONAL STATEMENTS

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