Insurance Vehicle Suspension Form

INSURANCE VEHICLE SUSPENSION FORM

1. Insured / Applicant Information

Date of Birth:

2. Policy Details

Policy Number:

Coverage Limit: Deductible:

Annual Premium:

Policy Period: From to

3. Vehicle Information

Year: VIN:

4. Suspension Request

Type of Suspension: Temporary Permanent

Requested Effective Date: If temporary, Anticipated Reinstatement Date:

Reason for Suspension (select applicable):

5. Coverage Affected by Suspension

Check each coverage to be suspended. Any coverage not checked remains in force subject to policy terms and minimum statutory limits.

I request suspension of all coverages except state minimum liability (if permitted by applicable law and policy terms)

6. Exclusions and Conditions

I acknowledge and agree that suspension of coverages is subject to the following conditions and exclusions:

• Suspension does not relieve the insured of contractual obligations or scheduled premiums unless insurer issues a written premium adjustment.
• Coverage will not apply to accidents, theft, or loss occurring while the vehicle is used in a prohibited manner, operated by an excluded driver, or while registered as active in jurisdictions that require continuous coverage.
• Suspension may require receipt of documentation (title, lienholder consent, storage receipts) before effective processing.
• Insurer retains the right to deny suspension or to require inspection prior to reinstatement.

7. Beneficiary for Refund or Premium Credit

Complete beneficiary information for allocation of any refund or premium credit resulting from an approved suspension.

Relationship to Insured: Percentage of Refund:

8. Documentation Checklist (attach required documents)

Please indicate the documents provided with this suspension request:

9. Certifications and Acknowledgements

By signing below, the undersigned certifies, warrants and agrees as follows:

1. The information supplied in this request is true and complete to the best of my knowledge and belief. I understand that materially false statements may constitute grounds for denial of the request and may be subject to criminal or civil penalties.
2. I authorize the insurer to verify any information provided and to obtain records relevant to this suspension request from third parties, including lienholders, storage facilities, and motor vehicle registries where permitted by law.
3. I understand that suspension of coverages may affect premium and future rating, and that reinstatement may be subject to inspection, payment of applicable premiums, and underwriting approval.
4. I agree to notify the insurer immediately if the vehicle is returned to operation, sold, transferred, repossessed, or otherwise changes status prior to the requested reinstatement date.
5. If a lienholder is listed or affected, I affirm that the lienholder has been notified of this suspension request and any consent required will be provided prior to processing.

10. Applicant Declaration

I declare under penalty of perjury under applicable law that the foregoing is true and correct. I understand that approval of the suspension is at the insurer's discretion and that no coverage change is effective until acknowledged in writing by an authorized representative of the insurer.

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