AUTO INSURANCE DATA VEHICLE I.D. CARD

Mark all that apply (please print):

Car____                 Van____                 Truck____            Wagon/SUV/Jeep____           Motor cycle/bike____

 Automatic____     Stick____               Radio____            Stereo/CD____                      Custom vehicle_____

Full Name:                                                                                                                                                

Street Address:                                                                                                                                      

City:                                                                         State:                            Zip:                                   

Class:                                                     Year:                     

Model:                                                                                                                 

License Plate #:                                   VIN#:                                                                                     

                                                     (OPTIONAL)

Insurance agent’s name:                                                                    Expires:                              

Issue date:                                                           Policy #:                                                                 

Medical condition (Y / N)                                  Emergency #:                                                       

Disabled (Y / N):                                                 Alarm (Y / N):             

Vehicle Marking(s):                                                                                                                           

                                                           (Examples: scratched, dented, sticker, etc.)

Vehicle Color(s):                                                                                                                               

                                                               CERTIFICATION

I hereby certify that all information contained herein is true and accurate to the

best of my knowledge for Insurance Data.  I agree to hold harmless and free

of all liability (for whatsoever reason) this company and all its personnel. 

NO WARRANTIES IMPLIED.

Print Name:                                                                                            

Signature:                                                                                                      Date: