Certification Of Consent To The Towing And Release To An Insurer Of A Motor Vehicle Form
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1CERTIFICATION OF CONSENT TO THE TOWING AND RELEASE TO AN
INSURER OF A MOTOR VEHICLE
TO: ___________________________________________________________________ (“Releasor”)
(Name of Tow Company or Person Currently in Possession of Vehicle Described Below)
An insurer must obtain consent from the owner of a motor vehicle, or the owner’s authorized agent, to
take possession of the motor vehicle from an operator of a tow car. The owner’s authorized agent must
not be a representative, employee, or other agent of the insurer.
Vehicle Information
Make: ________________ Model: __________________ Year: ______ VIN: ____________________
Vehicle Owner: ______________________________________________________________________
Owner’s Authorized Agent (if applicable): ________________________________________________
Insurer: ____________________________________________________________________________
Insurer’s Employee or Authorized Representative: __________________________________________
Policy Number: _______________________
Claim Number: _______________________________
STATEMENT OF CONSENT: “On behalf of the Insurer, I hereby warrant that the Insurer has obtained
the explicit consent of the Vehicle Owner or the Owner’s Authorized Agent to have the vehicle towed
and released to the Insurer. I warrant that the Insurer has documented such consent and will be able to
produce evidence of such documentation at the request of the Owner or the Owner’s Authorized Agent.
This form does not, in any manner, transfer ownership of the vehicle and does not waive any rights or
prerogatives pertaining to such ownership. The Vehicle Owner retains all other rights, as provided under
applicable Nevada law, to consent to the subsequent treatment of the vehicle within the Insurer’s claim-
handling process.”
STATEMENT OF INDEMNIFICATION: “On behalf of the Insurer, I hereby warrant that the Insurer
will indemnify the Releasor for any liability relating to the release of the motor vehicle to the Insurer.”
AFFIRMATION OF TRUTH: “On behalf of the Insurer, I declare under penalty of perjury, and all other
applicable penalties under Nevada law, that the foregoing is true and correct.”
________________________________________________________________________________________________
_________________________
Employee of Insurer or Insurer’s Authorized Representative
Date
___________________________________________________________
_____________________________________________________________
(Name of tow company taking possession of vehicle on Insurer’s behalf)
(Telephone number of tow company taking possession of vehicle)
______________________________________________________________________________________________________________________________
(Address of tow company taking possession of vehicle)
No towing on behalf of the Insurer may commence until the consent of the Owner or the Owner’s
Authorized Agent has been obtained and this form has been completed by an employee of the Insurer or
the Insurer’s Authorized Representative.
Rev. 9/27/2012
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