Insurance Certification Form printable pdf download

Insurance Certification Form

Clear Form

RENEWAL

Download

OF GUAM VEHICLE REGISTRATION

DEPARTMENT OF REVENUE AND TAXATION MOTOR VEHICLE DIVISION

Hours of Operation: 8:00a.m.

4:00p.m. M-F

—

REQUIREMENTS:

For owners (Registrants) of vehicle:

Complete Part A below.

If you are registering for the owner (A Non-registrant):

Complete Parts A & B below.

ART

Required information: (1)

Current automobile insurance in owners’ names and fill out certification form below.

(2)

Current vehicle safety inspection

If owner has an outstanding traffic citation, registration will be denied until

(3)

clearance is received from Traffic Court.

rINSURANCE CERTIFICATION F0Rfv~

YEAR

MAKE

MODEL

BODY STYLE

LICENSE NO.

ENGINE NO.

VEHICLE IDENTIFICATION NO.(VIN)

I HEREBY CERTIFY THAT THE INSURANCE COVERAGE OF THE VEHICLE DESCRIBED ABOVE IS NO LESS THAN THE FOLLOWING

MINIMUM AMOUNTS: $20,000 PROPERTY DAMAGE LIABILITY; $25,000 AND $50,000 THIRD PARTY BODILY INJURY LIABILITY FOR

EACH PERSON AND FOR ALL PERSONS RESPECTIVELY, IN ANY ONE ACCIDENT.

I FURTHER CERTIFY THAT THE FOLLOWING

INFORMATION IS TRUE AND CORRECT:

Policy Holder:

Insurance Company:

Expiration Date:

Vehicle Insurance Policy Number: ___________________________________________________________________

Registrant’s Telephone Numbers: Work:

Home:

____________________________

_____________________

Registrant’s Full Name (print):

Social Security No.:

____________________________

______________

Registrant’s Signature: ___________________________________________________ Date:

___________________________

Method ofPayment: Cash, check or credit card (Visa & Mastercard only and charges must be made before 4:00 p.m)

ARTB

Under penalty of perjury, I

hereby declare that

Non-registrant (Print Full Name)

Registrant (Print Full Name) granted

me full permission to register the vehicle described above. I further declare and certify that all the information

contained herein regarding the vehicle, to the best of my knowledge and belief, is true, correct and complete.

Non-registrant’s Signature

Non-registrant’s Social Security No.

Telephone No. (Worklllome)

(Rev 7/04)

See reverse for insurance law information.

Insurance Certification Form

Related Articles

Related forms

Related Categories