Preinspection of Private Passenger Motor Vehicles Forms

Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg. 69-2 Cranston, Rhode Island 02920 Insurance Bulletin Number 2018-5 Forms for compliance with 230-RICR-20-05-5 The following forms are designated for use in compliance with 230-RICR-20-05-5 – Preinspection of Private Passenger Motor Vehicles: FORM A INSURANCE COMPANY LETTERHEAD OR INSPECTION SERVICE LETTERHEAD ___________ __________ _________________ _______________ ___________ Date of Time of Insurance Company Insured's Policy Number of Inspection Inspection Name Number Photos ______ AM ______ PM Insured's Name Insured's Address Telephone No. Inspector's Name Inspection Site Name and Address Telephone No. Style Color Interior Year: ( ) 2 Dr ( ) SUV __________ ( ) Cloth ( ) Leather Make: ( ) 4 Dr ( ) Van/Minivan ( ) Vinyl ( ) Color Model: ( ) Coupe ( ) Hatchback ( ) Other __________ ( ) Other __________ Odometer Reading Principal Place Vehicle Identification License Plate No. of Garaging Number and Location and State ACCESSORIES AND OPTIONAL EQUIPMENT Describe: ______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ cc: Insurance Company Producer of Record nd Location and State ACCESSORIES AND OPTIONAL EQUIPMENT Describe: ______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ cc: Insurance Company Producer of Record FORM A (Con’t) PHOTOGRAPHS OF VEHICLE (MUST BE COLOR PHOTOS) ATTACH AT LEAST TWO (2) COLOR PHOTOGRAPHS OF THE AUTOMOBILE TAKEN FROM THE FRONT AND PASSENGER SIDE AND THE REAR AND DRIVER SIDE. ALSO ATTACH CLOSE-UP PHOTO OF THE EPA STICKER FROM THE DRIVER'S SIDE DOOR JAMB. PHYSICAL CONDITION OF VEHICLE (CHECK DAMAGED AREAS OR AREAS IN POOR CONDITION AND DESCRIBE BELOW) DAMAGED RUSTED DAMAGED ( ) ( ) FRONT BUMPER ( ) WINDSHIELD ( ) ( ) LEFT FRONT FENDER ( ) LEFT FRONT SIDE GLASS ( ) ( ) LEFT FRONT DOOR ( ) RIGHT FRONT SIDE GLASS ( ) ( ) LEFT REAR DOOR ( ) LEFT REAR SIDE GLASS ( ) ( ) LEFT REAR QUARTER PANEL ( ) REAR WINDOW ( ) ( ) REAR BUMPER ( ) REARVIEW MIRROR ( ) ( ) REAR DOOR/TRUNK LID ( ) WHEEL COVERS ( ) ( ) RIGHT REAR QUARTER PANEL ( ) WORN/TORN OR SOILED ( ) ( ) RIGHT REAR DOOR INTERIOR ( ) ( ) RIGHT FRONT DOOR ( ) OTHER DAMAGE OR ( ) ( ) RIGHT FRONT FENDER RUST (LIST) ( ) ( ) HOOD PANEL ______________________ ( ) ( ) ROOF PANEL ______________________ ( ) ( ) GRILL ______________________ ( ) CHECK HERE IF NO EXISTING DAMAGE, RUST, OR MISSING PARTS _____________________________________________________________________________________ DESCRIBE EXISTING DAMAGES OR RUST: _____________________________________________________________________________________ LIST ANY MISSING PARTS: _____________________________________________________________________________________ DESCRIBE ANY ALTERATIONS FROM FACTORY DESIGN: _____________________________________________________________________ _________________________________________ DESCRIBE EXISTING DAMAGES OR RUST: _____________________________________________________________________________________ LIST ANY MISSING PARTS: _____________________________________________________________________________________ DESCRIBE ANY ALTERATIONS FROM FACTORY DESIGN: _____________________________________________________________________________________ The above is a true statement of any existing damage, rust, or missing parts as of the date of this inspection. I certify that this inspection report is true and complete and that I have seen and photographed the vehicle identified above. Date: ______ Inspector's Signature: ___________________________________ _____________________________________________________________________________________ Name and Address of Person Presenting Signature Relationship Vehicle for Inspection to Insured cc: Insurance Company Producer of Record FORM B NOTICE OF MANDATORY PRE-INSURANCE INSPECTION REQUIREMENT (THIS IS NOT A SAFETY INSPECTION) IMMEDIATE ACTION REQUIRED TO AVOID LOSS OF INSURANCE COVERAGE _________________ DATE OF MAILING Name of Insured: ______________________________ Effective Date of Coverage _____________ Address: ______________________________ ______________________________ Inspection Must be ______________________________ Completed by: ____________ Policy Number: ___________________ Dear Policyholder, This will confirm coverage for Physical Damage Coverage on your: YEAR MAKE MODEL 1. _______________ _________________ __________________ 2. _______________ _________________ __________________ 3. _______________ _________________ __________________ Please disregard this notice if you have already had your car inspected mber: ___________________ Dear Policyholder, This will confirm coverage for Physical Damage Coverage on your: YEAR MAKE MODEL 1. _______________ _________________ __________________ 2. _______________ _________________ __________________ 3. _______________ _________________ __________________ Please disregard this notice if you have already had your car inspected. This notice will also serve as a reminder that the above described car(s) must be inspected by the date indicated above, or your Physical Damage Coverage will be suspended effective 12:01 a.m. on _______________. Date I further understand that if Physical Damage Coverage is suspended, unless I return the enclosed rejection of uninsured motorist coverage for loss resulting from damage to property by the cancellation date, such coverage will be added in accordance with R.I. Gen. Laws § 27-7-2.1(b) and the premium will be adjusted accordingly. If you have your car inspected after the above deadline your Physical Damage Coverage will only be restored after your car has been inspected and the adjusted premium due for the Physical Damage Coverage has been paid. At the time Physical Damage Coverage is restored, uninsured motorist coverage for loss resulting from damage to property will be terminated and the premium adjusted accordingly, unless you choose to purchase that coverage. You will have no Physical Damage Coverage for any physical damage loss that occurs during the suspension period. FOR FURTHER INFORMATION PLEASE CALL: _________________________________________ Name and Phone Number of Company Representative Very truly yours, ______________ cc: Insurance Company Producer of Record djusted accordingly, unless you choose to purchase that coverage. You will have no Physical Damage Coverage for any physical damage loss that occurs during the suspension period. FOR FURTHER INFORMATION PLEASE CALL: _________________________________________ Name and Phone Number of Company Representative Very truly yours, ______________ cc: Insurance Company Producer of Record FORM C (COMPANY LETTERHEAD) NOTICE OF SUSPENSION OF PHYSICAL DAMAGE COVERAGE YOU ARE NO LONGER INSURED FOR PHYSICAL DAMAGE TO YOUR CAR _________________ DATE OF MAILING Name of Insured: _____________________ Effective Date of Coverage ____________ Address: _____________________ _____________________ _____________________ Policy Number: ______________ Dear Policyholder The vehicle(s) listed below is (are) no longer covered for Physical Damage Coverage: YEAR MAKE MODEL 1. _______________ _________________ __________________ 2. _______________ _________________ __________________ 3. _______________ _________________ __________________ DATE OF COVERAGE WAS REQUESTED _____________ DATE OF COVERAGE WAS SUSPENDED _____________ The Physical Damage Coverage indicated above, has been suspended on the vehicle(s) described, effective 12:01 a.m. on the suspension date. Such coverage has been suspended due to your failure to comply with Regulation 77, as required by R.I. Gen. Laws § 27-10.1-10. If your coverage has been suspended for more than ten (10) days, you will receive a premium adjustment (return premium or credit) for the suspended coverage(s) within forty-five (45) days from the date of suspension. Unless you have rejected in writing uninsured motorist coverage for loss resulting from damage to property by the suspension date, such coverage will be added and the premium will be adjusted accordingly n suspended for more than ten (10) days, you will receive a premium adjustment (return premium or credit) for the suspended coverage(s) within forty-five (45) days from the date of suspension. Unless you have rejected in writing uninsured motorist coverage for loss resulting from damage to property by the suspension date, such coverage will be added and the premium will be adjusted accordingly. The Physical Damage Coverage(s) will be restored when you have your vehicle(s) inspected and the adjusted premium due for such coverage(s) has been paid. At the time Physical Damage Coverage is restored, uninsured motorist coverage for loss resulting from damage to property will be terminated and the premium adjusted accordingly, unless you choose to purchase that coverage. __________________________ INSURER REPRESENTATIVE ________________ PHONE NUMBER cc: Producer of Record Lienholder FORM D ACKNOWLEDGMENT OF REQUIREMENT FOR PRE-INSURANCE INSPECTION (THIS IS NOT A SAFETY INSPECTION) Name of Insured Effective Date of Coverage ____________ or Applicant: __________________________ Address: __________________________ Inspection Must be __________________________ Completed by __________ __________________________ VEHICLES TO BE INSPECTED YEAR MAKE MODEL 1. 2. 3. By my signature below, I certify that I have been informed that my vehicle(s) which is (are) being insured for Physical Damage Coverage must be inspected by a representative of the insurer. This inspection must be completed within ten (10) business days after the effective date of coverage, and in no event later than the date shown above to avoid a suspension in coverage. I understand that failure to submit to the required inspection(s) will result in the suspension of Physical Damage Coverages as of 12:01 a.m amage Coverage must be inspected by a representative of the insurer. This inspection must be completed within ten (10) business days after the effective date of coverage, and in no event later than the date shown above to avoid a suspension in coverage. I understand that failure to submit to the required inspection(s) will result in the suspension of Physical Damage Coverages as of 12:01 a.m. of the day following the date by which the inspection must be completed, as shown above. I further understand that if Physical Damage Coverage is suspended, unless I return the enclosed rejection of uninsured motorist coverage for loss resulting from damage to property by the cancellation date, such coverage will be added in accordance with R.I. Gen. Laws § 27-7-2.1(b) and the premium will be adjusted accordingly. I understand that if Physical Damage Coverage is suspended it will be restored only after the inspection has been completed and the adjusted premium due for such coverage(s) has been paid. . At the time Physical Damage Coverage is restored, uninsured motorist coverage for loss resulting from damage to property will be terminated and the premium adjusted accordingly, unless you choose to purchase that coverage. Signature of Insured or Applicant: _______________________ Date: ________________ Signature of Producer or Insurance Company Representative: ______________________________ Date: ________________ Name, Address and Telephone Number of Producer or Insurance Company Representative Completing This Form: _________________________________ _________________________________ _________________________________ INSURED/APPLICANT MUST RECEIVE A COMPLETED COPY OF THIS FORM cc: Insurance Company Producer of Record