// Mason-McBride / Insurance and Financial Services //

BUSINESS INSURANCE SERVICES
• Property/Casualty
• Employee Group Programs
• Compliance Check
• Benefits is our Business

PERSONAL INSURANCE SERVICES
• Individual BCBS Coverage

FINANCIAL & INVESTMENT SERVICES

MASON-MCBRIDE CAPITAL ADVISORS, LLC

SUMMIT RISK MANAGEMENT, LLC

NEWSLETTERS

Request for AUTOMOBILE Proof of Coverage

Click here for a printable version of this form (PDF format)

REQUESTOR INFORMATION SECTION

Requestor's Name:
Requestor's Company:
Requestor's Address:
Requestor's City:
Requestor's State:
Requestor's Zip:
Requestor's Email:
Requestor's Phone:
Requestor's Fax:

CLIENT INFORMATION SECTION

Name:
Address:
City:
State:
Zip:

DESCRIPTION OF AUTOMOBILES

Trade-in Info:

Year:
Make:
Model:
Vehicle ID Number:
Date of Trade-In:

New Vehicle Info:

Year:
Make:
Model:
Vehicle ID Number:

Will the title be held by a bank or lessor:	Yes No
How should the bank or lessor be named on the client's policy:
Does the bank/lease agreement require a min limit:	Yes No
Limit:
Is there a maximum physical damage deductible:	Yes No

Comprehensive Deductible Max.:
Collision Deductible Max:
Type:
Date of Sale:
Cost New:

Remarks:

NOTE: This form is available for banks or lessors to request proof of coverage on behalf of our client. Upon receipt of this completed form, we will verify coverage and complete the requested proof of coverage and will send to the Requestor’s email address listed below.

Terms and Conditions