Insurance Company Application and Statement of Fact … · Insurance Company Application and...
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Insurance Company Application and Statement of Fact for Hurricane Harvey Impacted Vehicles **Application for Nonrepairable Vehicle Title or Certificate of Authority Only** Instructions This form may only be used by an insurance company licensed to do business in Texas that acquired ownership or possession of a motor vehicle through payment of a claim as a result of Hurricane Harvey and its aftermath. Additionally, this form is a joint application for a Texas Nonrepairable Vehicle Title or a Certificate of Authority to Dispose of a Motor Vehicle to a Demolisher. “County of Occurrence” must be in one of the counties in the Governor’s Disaster Proclamation. This form is only valid for claims paid on or before December 31, 2017. This form is not acceptable with an application for a Texas Certificate of Title or a Salvage Vehicle Title. Required Documents to Transfer Ownership into the Insurance Company’s Name: 1. Insurance Company Application and Statement of Fact for Hurricane Harvey Impacted Vehicles (Form VTR-441-HRV). 2. Certificate of Title (if available) – any unassigned or improperly assigned title in the insurance company's possession. 3. Proof of Paid Claim – a copy of the payment document indicating the insurance company has made payment of a claim involving the motor vehicle, including an electronic check, canceled check, or screen print from the insurance company's database that identifies the type of payment method. 4. Vehicle Identification Number (VIN) Verification – only required for vehicles last titled outside of Texas. The VIN can be verified by checking the applicable box in the “Certification” section. Submit this form to: Regular Mail: Texas Department of Motor Vehicles Vehicle Titles and Registration Division ATTN: Title Control Systems P.O. Box 26450 Austin, Texas 78755-0450 Express Mail: Texas Department of Motor Vehicles Vehicle Titles and Registration Division ATTN: Title Control Systems 4000 Jackson Ave. Austin, Texas 78731 Application Type Check one: ☐ Nonrepairable Vehicle Title ($8.00 fee) ☐ Certificate of Authority* ($2.00 fee) * A Certificate of Authority may only be used to transfer the vehicle to a demolisher for permanent destruction. The vehicle cannot be used for parts. Vehicle Information Vehicle Identification Number Year Make Body Style Model . Title/Document Number (if unknown, leave blank) Previous Title State License Plate State and Number (if any) Odometer Reading (no tenths) This is the Actual Mileage unless the mileage is: ☐ Exempt ☐ Not Actual ☐ Exceeds Mechanical Limits Type of Damage: ☐ Accident/Collision ☐ Flood Damage ☐ Other (specify) If the vehicle was last titled outside of Texas, please indicate the connection to Texas: ☐ Damage occurred in Texas ☐ The owner from whom the insurance company acquired ownership is a Texas resident Insurance Company Information Name Claim Payment Date County of Occurrence Address City State Zip Authorized Agent First Name Middle Name Last Name Suffix (if any) Email (optional) Phone Number (optional) Certification – State law makes falsifying information a third degree felony I certify I am an authorized agent of the insurance company named above, a loss claim was paid and accepted for this vehicle, the claim was paid as a result of Hurricane Harvey or its aftermath, and the surrender or proper assignment of the original vehicle title was not possible. The statements on this application for the vehicle described above are true, and we have been transferred ownership of the vehicle. ☐ This vehicle was previously titled out of state. Therefore, I certify the insurance company has made a physical inspection of the vehicle and found the permanent vehicle identification number to be as indicated above. Printed Name (Same as Signature) Date Signature of Authorized Agent VTR-441-HRV Rev 09/17 Form available online at www.TxDMV.gov Page 1 of 1
Transcript of Insurance Company Application and Statement of Fact … · Insurance Company Application and...
Insurance Company Application and Statement of Fact for Hurricane Harvey Impacted Vehicles
**Application for Nonrepairable Vehicle Title or Certificate of Authority Only**
Instructions This form may only be used by an insurance company licensed to do business in Texas that acquired ownership or possession of a motor vehicle through payment of a claim as a result of Hurricane Harvey and its aftermath. Additionally, this form is a joint application for a Texas Nonrepairable Vehicle Title or a Certificate of Authority to Dispose of a Motor Vehicle to a Demolisher. “County of Occurrence” must be in one of the counties in the Governor’s Disaster Proclamation. This form is only valid for claims paid on or before December 31, 2017. This form is not acceptable with an application for a Texas Certificate of Title or a Salvage Vehicle Title.
Required Documents to Transfer Ownership i nto the Insurance Company’s Name: 1. Insurance Company Application and Statement of Fact for Hurricane Harvey Impacted Vehicles (Form VTR-441-HRV). 2. Certificate of Title (if available) – any unassigned or improperly assigned title in the insurance company's possession. 3. Proof of Paid Claim – a copy of the payment document indicating the insurance company has made payment of a claim
involving the motor vehicle, including an electronic check, canceled check, or screen print from the insurance company's database that identifies the type of payment method.
4. Vehicle Identification Number (VIN) Verification – only required for vehicles last titled outside of Texas. The VIN can beverified by checking the applicable box in the “Certification” section.
Submit this form to: Regular Mail: Texas Department of Motor Vehicles Vehicle Titles and Registration Division ATTN: Title Control Systems P.O. Box 26450 Austin, Texas 78755-0450
Express Mail: Texas Department of Motor Vehicles Vehicle Titles and Registration Division ATTN: Title Control Systems 4000 Jackson Ave. Austin, Texas 78731
Application Type Check one:
☐ Nonrepairable Vehicle Title ($8.00 fee) ☐ Certificate of Authority* ($2.00 fee) * A Certificate of Authority may only be used to transfer the vehicle to a demolisher for permanent destruction. The vehicle cannot be used for parts.
Vehicle Information Vehicle Identification Number Year Make Body Style Model
.
Title/Document Number (if unknown, leave blank) Previous Title State License Plate State and Number (if any)
Odometer Reading (no tenths) This is the Actual Mileage unless the mileage is: ☐ Exempt ☐ Not Actual ☐ Exceeds Mechanical Limits
Type of Damage:
☐ Accident/Collision ☐ Flood Damage ☐ Other (specify) If the vehicle was last titled outside of Texas, please indicate the connection to Texas:
☐ Damage occurred in Texas ☐ The owner from whom the insurance company acquired ownership is a Texas resident
Insurance Company Information Name Claim Payment Date County of Occurrence
Address City State Zip
Authorized Agent First Name Middle Name Last Name Suffix (if any)
Email (optional) Phone Number (optional)
Certification – State law makes falsifying information a third degree felony I certify I am an authorized agent of the insurance company named above, a loss claim was paid and accepted for this vehicle, the claim was paid as a result of Hurricane Harvey or its aftermath, and the surrender or proper assignment of the original vehicle title was not possible. The statements on this application for the vehicle described above are true, and we have been transferred ownership of the vehicle. ☐ This vehicle was previously titled out of state. Therefore, I certify the insurance company has made a physical inspection of the vehicle and
found the permanent vehicle identification number to be as indicated above.
Printed Name (Same as Signature) Date
Signature of Authorized Agent
VTR-441-HRV Rev 09/17 Form available online at www.TxDMV.gov Page 1 of 1
