Transcription of NEW YORK E-SITE INSURANCE INSPECTION WORKSHEET - …
1 NEW YORKE- site INSURANCE INSPECTION WORKSHEETThis is not an official INSPECTION until electronically submitted byan authorized INSPECTION site and received and assigned a control # by OF INSPECTIONTIMEADVERSE CONDITIONS DARKNESS INCLEMENT WEATHERINSURANCE CO. NAMEPOLICY/APPLICATION THIS A COMMERCIAL VEHICLE? YESNO. PHOTOSINSURED'S NAME (Last, First))INSURED'S ADDRESSTOWNSTATEZIP/POSTAL CODEINSURED'S HOME PHONEINSURED'S WORK PHONEINSURED'S EMAIL ADDRESSIs the person with the vehicle theinsured? YES NOIf you answer NO, please fill-inboxes to the NAME, FIRST NAMERELATION TO CAR OWNERADDRESSTOWNSTATEZIP/POSTAL CODEBROKER/AGENT NAMEYESNOINSURANCE AUTHORIZATIONFORM SUPPLIED BY INSUREDFORM NUMBER:INSPECTORINSPECTION site NAMESITE LOCATION(Address) site OF VEHICLEYEARMAKEMODELCOLOR MAJORCOLOR MINORSTYLE 2 DR. 4 DR.
2 CONVT. OTHER ST. WGN. HTCHBK VAN SUV MINIVAN TRUCK MOTRCYCLTRANSMISSION MANUAL 3 SPD MANUAL 4 SPD MANUAL 5 SPD AUTOMATIC AUTOMATIC WITH OVERDRIVESEAT MATERIAL VINYL FABRIC LEATHERFRONT SEATCOLOR(S)VEHICLE IDENTIFICATION NO. (Obtain Directly from Vehicle)PLATE NOSTATEEXACT ODOMETER READING (DO NOT INCLUDE TENTHS)LOCATION ON VEHICLE WHERE VIN OBTAINED DASHBOARD OTHERTHREE (3) COLOR PHOTOGRAPHS MANDATORYTAKE THE PHOTOGRAPHS AT THE ANGLES AND DRIVER AND PASSENGER SIDEEPA Sticker (on Door Jamb)Showing VIN NUMBEREPA photo ALWAYS Required -Even if EPA Sticker Missing, CHECK BOX IFEPA Sticker Not Clear - Photo TakenEPA Sticker Missing - Photo TakenPRINCIPLE LOCATION WHERE VEHICLE IS KEPT SAME AS INSURED'S ADDRESS OTHER - PLEASE SPECIFYCITY:STATE/PROVINCE:RADIO EQUIPMENT NONE AM/FM AM/FM CASSETTE CD PLAYER CD CHANGER FACTORY INSTALLEDOr After Brand: GPS/NAVIGATION SYSTEM CB RADIO Brand: PERMANENTLY INSTALLED PHONEANTITHEFT DEVICE NONENAME/MODEL:MANUFACTURER/BRAND.
3 SYSTEM PRESENT,BUT INOPERATIVE AUTO RECOVERY SYSTEM PASSIVE DISABING DEVICE(Automatically Engages) ACTIVE DISABLING DEVICE(Must be manually engaged) SIREN/AUDIBLE ALARM ONLY COMBAT AUTO THEFT(CAT) Issued Rear Window Sticker ETCHED GLASS INDICATING VIN OR CODINGEXTERIOR CUSTOM/MAG WHEELS SPECIAL HUB CAPS Quantity on Vehicle: SPECIAL TIRES - Type: SPOILER SUNROOF/MOONROOF Motorized REAR WINDOW WIPER DAYTIME RUNNING LIGHTS VINYL/CANVAS TOP OTHER ROOF Type:SEATS AUTOMATIC SEAT BELTS POWER SEATS BUCKET SEATS 60/40 SEATS HEATED SEATS LUMBARINSTRUMENTATION AIR CONDITIONER DIGITAL INSTRUMENTATION CRUISE CONTROL TILT WHEEL POWER WINDOWS POWER DOOR LOCKS POWER STEERING POWER ANTENNA POWER TRUNKSAFETY ANTI-LOCK BRAKES FRONT AIR BAGS 1 2 SIDE AIR BAGS 1 2 OTHER OPTIONAL EQUIPMENT: CHECK HERE IF THIS IS A VAN OR LIMOVAN & LIMO SUPPLEMENT INTERIOR PANELING REAR PASSENGER SEATING EXTERIOR DECORATIVE PAINT NON-FACTORY INSTALLED AC CUSTOMIZED WINDOWS BEDS - No.
4 STEREO REFRIGERATOR TELEVISION/VCR/DVD PERMANENT/INSTALLED YES NO OTHER -PHYSICAL CONDITION OF VEHICLE CHECK HERE IF NO EXISTING DAMAGE, RUST OR MISSING PARTSDAMAGED:RUSTED:01 FRONT BUMPER02 REAR BUMPER03 FENDER LEFT FRONT04 FENDER RIGHT FRONT05 DOOR LEFT FRONT06 DOOR RIGHT FRONT07 DOOR LEFT REAR08 DOOR RIGHT REARDAMAGED:RUSTED:09 QUARTER PANEL LEFT REAR10 QUARTER PANEL RIGHT REAR11 HOOD PANEL12 ROOF PANEL13 TRUNK LID/REAR DOOR14 GRILL15 WHEEL COVERS16 WINDSHIELDDAMAGED: 17 SIDE GLASS LEFT FRONT18 SIDE GLASS RIGHT FRONT19 SIDE GLASS LEFT REAR20 SIDE GLASS RIGHT REAR21 REAR WINDSHIELD22 WORN, TORN, INTERIOR/SEATS23 DASHBOARD/SOUND SYSTEM26 CENTER CONSOLE90 OTHER DAMAGEUSE THIS SPACE TO FURTHER DESCRIBE ANY RUST, MISSING PARTS, OR MAJOR ALTERATIONS (PLEASE TAKE ADDITIONAL PHOTO(S) OF DAMAGE)I HAVE REVIEWED THIS REPORT, AND ACKNOWLEDGE THAT IT IS A COMPLETE DESCRIPTION OF THE AUTO'S PHYSICAL CONDITION AND ACCESSORY ITEMS.
5 The inspectorcertifies, under penalty of perjury, that this INSPECTION report is true and complete to the best of his/her knowledge and that a copy of this inpsection shall be provided to driver.
