Appendix A

Claim Number: __________ Date: __________________ Appraiser: ______________ IMPORTANT NOTICE: 1. Your vehicle has sustained damage such that it may no longer meet the annual safety or emissions inspection standards. Your vehicle has such damage to the following item(s): 2. Massachusetts General Laws and 540 CMR 19.00 nowrequire that the Certificate of Inspection be replaced by a Temporary Certificate of Inspection whenever a Licensed Damage Appraiser determines that a vehicle is damaged such that it may no longer meet the annual safety or emissions inspection standards. 3. The appraiser was unable to replace the Certificate of Inspection with a Temporary Certificate of Inspection due to the following: a. Vehicle locked __ b. Other (explain) ____________ 4. You must arrange for the replacement of your Certificate of Inspection with a Temporary Certificate of Inspection immediately, or alternatively, have the vehicle repaired so that it may pass the safety and emissions standards and obtain a new Certificate of Inspection immediately. Failure to do so may result in a delay in settling your claim with the insurance company. The following are authorized to replace the Certificate of Inspection with a Temporary Certificate of Inspection at no charge to you: a. Any Licensed Auto Damage Appraiser b. Any Registry of Motor Vehicle Inspector 5. The Temporary Certificate of Inspection is valid for a period of 20 days. The damage which required the replacement of the Certificate of Inspection must be repaired before the expiration of the 20 day period. Operating a vehicle without a valid Certificate of Inspection will subject the operator to fines and insurance surcharges. 6. You must return a copy of this form signed by one of the authorized individuals specified in 4a. or b. above attestingto the replacementofthe Certificate of Inspection with the Temporary Certificate to the addressspecified below. I, ____________________________________________________________________ replaced Name Appraiser Lic.# or Badge Department Date Certificate of Inspection, Serial Number ______________________________ with Temporary Certificate of Inspection, Serial Number ______________________________. 7. Return this form to: _____________________________________ _____________________________________ _____________________________________ This form approved by the Commissioner of Insurance and the Registrar of Motor Vehicles. 3 parts: # 1 Motorist. # 2 Attach to Appraisal. # 3 Appraiser. NON-TEXT PAGE