Form M-496a - Automobile Inspection Report Template
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1G NATIONAL INDEMNITY COMPANY
G NATIONAL LIABILITY & FIRE INSURANCE COMPANY
G REDWOOD FIRE AND CASUALTY INSURANCE COMPANY
G NATIONAL FIRE & MARINE INSURANCE COMPANY
G NATIONAL INDEMNITY COMPANY OF FLORIDA
G WESCO-FINANCIAL INSURANCE COMPANY
G COLUMBIA INSURANCE COMPANY
G NATIONAL INDEMNITY COMPANY OF MID-AMERICA
G KANSAS FIRE & CASUALTY COMPANY
AUTOMOBILE INSPECTION REPORT
Name of Insured
Policy No.
Address
Description of the automobile and/or trailer inspected:
MOTOR OR
YEAR
TRADE NAME
STYLE OF BODY
LOAD CAPACITY
NO. CYLINDERS
SERIAL NO
Are the following items in good condition and functional? Please check Yes or No block, and comment if necessary on Items
1 through 10.
Yes
No
Comments
G
G
1. Speedometer
G
G
2. Horn
G
G
3. Windshield Wipers
G
G
4. Mirrors
G
G
5. Headlights
G
G
6. Tail Lights
G
G
7. Stop Lights
G
G
8. Turn Signals
G
G
9. Steering
G
G
10. Brakes
11. What is condition of tires? (If unsatisfactory, indicate which ones and condition.)
12. Condition of windows. If any unsatisfactory (cracked, broken, etc.), indicate which ones and condition.
13. What is general mechanical condition?
14. What is general appearance of body as to paint upkeep, etc.?
15. Does auto appear properly greased?
16. In addition to any defects disclosed above, what changes or repairs are necessary to place the vehicle in safe driving
condition?
I hereby certify the answers and statements to the above are correct and are made after inspection of this vehicle by:
(NAME OF GARAGE)
(DATE INSPECTED)
(SIGNATURE OF PROPRIETOR OR MECHANIC)
M-496a (1/89)
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Parent category: Business