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New California Law
Effective January 1st.
2005

Did you know that if
you allow your
insurance to cancel the
DMV will cancel your
vehicle registration?
Insure your vehicles
Today!

SR Filing-No Problem
Tickets- Accidents- DUI
OK

Need to register your vehicle?
Now you may insure and
register your vehicle at
Recovery Insurance Services

First Name:

Last Name:

Home Phone:

Work Phone:

EXT.

Cell Phone:

E-Mail Address:

Garaging Address:

Mailing Address:

Driver Information

Named Insured must be registered
owner of the Vehicle or Spouse, unless
vehicle recently purchased.

Driver # 1
(Note! Named
Insured)

NOTE! Skip additional driver
information if no more drivers.

First Name:

Last Name:

Birth Date:

Sex:

Marital Status:

Prior Insurance:

Exp. Date:

Exclude Register Owner:

Licensed

Yrs

California:

California Driver License #:

Verifiable U.S.:

Violations (past three years)

International:

SR Filling:

Driver # 2

First Name:

Last Name:

Birth Date:

Sex:

Marital Status:

Prior Insurance:

Licensed

Yrs

California:

California Driver License #:

Verifiable U.S.:

Violations(past three years)

International:

SR Filling:

Driver # 3

First Name:

Last Name:

Birth Date:

Sex:

Marital Status:

Licensed

Yrs

California:

California Driver License #:

Verifiable U.S.:

Violations(past three years)

International:

SR Filling:

Driver # 4

First Name:

Last Name:

Birth Date:

Sex:

Marital Status:

Licensed

Yrs

California:

California Driver License #:

Verifiable U.S.:

Violations(past three years)

International:

SR Filling:

Vehicle Informations

Vehicle Year Make Model Salvage Use Vin. #

Vehicle #1:

Vehicle #2:

Liability Limits-Bodily Injury,
Property Damage covers losses
to the other party if you are at
fault.

Vehicle #3:

Vehicle #4:

Medical Payments-Apply to
the named insured and his/her
passengers.
Uninsured Motorist
Protraction- Applies to the
insured in case of an uninsured
motorist causes loss to
you/your vehicle and they are
at fault.

Coverages

Bodily Injury:

Note! If more than one vehicle, same
coverages apply for Bodily Injury,
Property Damage, Medical Payments
and Uninsured Motorist.

Property Damage:

Medical Payments:

Uninsured Motorist Bodily:

Uninsured Motorist Property Damage:

Comprehensive-Theft,
Vandalism, and any accidents
which doesn't involve other
objects.
Comprehensive-Accident
which involves other vehicles
and objects.

Deductibles

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Comprehensive:

Collision:

Rental/Towing:

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