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    Reg 492 R12 2022 As WWW

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    lovegoa3
    This document is an application for an unobtainable title certification to issue either a salvage certificate or nonrepairable certificate. It contains sections for vehicle description, insurance company information, applicant information, and certification. The applicant certifies that the vehicle described is a total loss salvage and requests a salvage or nonrepairable certificate be issued since the title is unobtainable despite attempts to obtain it from the previous owner.

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    © All Rights Reserved
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    Reg 492 R12 2022 As WWW

    Uploaded by

    lovegoa3
    24 views1 page
    This document is an application for an unobtainable title certification to issue either a salvage certificate or nonrepairable certificate. It contains sections for vehicle description, insurance company information, applicant information, and certification. The applicant certifies that the vehicle described is a total loss salvage and requests a salvage or nonrepairable certificate be issued since the title is unobtainable despite attempts to obtain it from the previous owner.

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    Original Title

    REG-492-R12-2022-AS-WWW

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    This document is an application for an unobtainable title certification to issue either a salvage certificate or nonrepairable certificate. It contains sections for vehicle description, insurance company information, applicant information, and certification. The applicant certifies that the vehicle described is a total loss salvage and requests a salvage or nonrepairable certificate be issued since the title is unobtainable despite attempts to obtain it from the previous owner.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views1 page

    Reg 492 R12 2022 As WWW

    Uploaded by

    lovegoa3
    This document is an application for an unobtainable title certification to issue either a salvage certificate or nonrepairable certificate. It contains sections for vehicle description, insurance company information, applicant information, and certification. The applicant certifies that the vehicle described is a total loss salvage and requests a salvage or nonrepairable certificate be issued since the title is unobtainable despite attempts to obtain it from the previous owner.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    APPLICATION FOR:

    CHECK ONE BOX


    Unobtainable Title Certification for Issuance of Salvage Certificate
    Unobtainable Title Certification for Issuance of Nonrepairable Certificate
    Authority Sections: CVC 11515 and 11515.2

    SECTION 1 — VEHICLE DESCRIPTION


    VEHICLE IDENTIFICATION NUMBER (VIN) VEHICLE LICENSE PLATE MAKE YEAR MODEL

    SECTION 2 — INSURANCE COMPANY


    NAME OF INSUR ANCE COMPANY

    ADDRESS CITY STATE ZIP CODE

    PRINTED NAME OF INDIVIDUAL OR BUSINESS RECEIVING SETTLEMENT ACCEPTANCE DATE OF SETTLEMENT (MM/DD/Y Y Y Y )

    SECTION 3 — APPLICANT FOR UNOBTAINABLE TITLE


    PRINTED NAME OF INSUR ANCE COMPANY, SALVAGE POOL, OR OCCUPATIONAL LICENSEE OF THE DEPARTMENT

    STREET ADDRESS CITY STATE ZIP CODE

    SECTION 4 — CERTIFICATION

    The undersigned certifies that the above described vehicle, for which a properly endorsed titling document or evidence of
    ownership is unobtainable, is a total loss salvage, and requests the Department of Motor Vehicles to issue a salvage certificate
    or nonrepairable certificate as appropriate.

    The undersigned has attempted to obtain the certificate of ownership or other acceptable evidence of title. The attempt to
    obtain the certificate of ownership or other acceptable evidence of title has been provided concurrently with the payment
    of the claim or by first-class mail, certificate of mailing, certified mail, other commercially available delivery service showing
    proof of delivery, or electronic mail.

    The undersigned is authorized to make this request on behalf of the insurance company, occupational licensee of the
    department, or salvage pool. I agree to indemnify and save harmless the Director of Motor Vehicles for any loss suffered
    resulting from the issuance of said salvage certificate or nonrepairable certificate.

    I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
    PRINTED LAST NAME FIRST NAME MIDDLE NAME DAYTIME TELEPHONE NUMBER

    ( )
    SIGNATURE DATE

    Print Clear form

    REG 492 (REV. 12/2022) WWW

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