Automobile Insurance Motor Vehicle Inspection Report Template - Alberta Superintendent Of Insurance
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1The Alberta Superintendent of Insurance has approved this form pursuant to section 803 of the Insurance Act.
AUTOMOBILE INSURANCE MOTOR VEHICLE INSPECTION REPORT
This Report is required only if the vehicles is 12 years or older and must be completed by a licensed mechanic.
Applicant/Insured Name: ______________________________
Vehicle Make: __________________
Policy Number: ________________________________
Vehicle Model: ______________________
VIN #: ________________________________
Vehicle Year: _______________________
This Section to be completed by a Licensed Mechanic
Roadworthy
Reject
Roadworthy
Reject
Steering
Electrical System
Steering Box/Rack
Head Lamps/Tail Lamps
Struts/Shocks
Stop Lamps
Front Suspension
Signal Lamps
Tie Rod Ends
Windshield Wipers
Tires
General Conditions
Front
Body Condition
Rear
Muffler/Exhaust
Motor
Brakes
Front Lining or Drums
Windshield
Rear Lining or Drum
Seat Belts
Park
Has the vehicle been
altered for speed or
Yes
No
performance
Brake Hoses
Is the vehicle roadworthy
Yes
No
Brake Lines
Mechanic’s Statements: I certify that I have inspected and tested the motor vehicle described above and
found it to be in the condition stated above.
Date:
_______________________________________________________
Signature of Qualified Mechanic:
_______________________________________________________
Mechanic’s Certificate No.:
_______________________________________________________
Automotive Repair Shop Name:
_______________________________________________________
Address:
_______________________________________________________
Telephone Number:
_______________________________________________________
8124AB-062005
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