Electronic Signature Agreement

In the case of an insurance company paying for a total loss damage of an automotive, the following agreement form has to be completed and submitted.

Extracted Text for Proper Search

FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES 	
 
ELECTRONIC SIGNATURE AGREEMENT  
 
This form may be used when an insurance company has paid a total loss claim on a vehicle and is using form 
HSMV 82053 (Power of Attorney) with the insured’s electronic signature (E-signature). 
 
This agreement may only be used when a licensed insurance company is applying for a certificate of 	
destruction on behalf of the insured.	 	
 
______________________________________________________________________________ located at  
Name of Insurance Company 
 
_____________________________________________________________________________________  
Business Address          City          State                  Zip   
 
has completed an E-signature process that allows the insured, who is the titled owner of the below described 
vehicle, to electronically sign and transmit a form HSMV 82053 (Power of Attorney) in lieu of providing a 
handwritten signature on the physical document and mailing it.  Our company is maintaining proof of this 
electronic signature. 
 
 
The following is the insured’s vehicle information for this E-signature Agreement: 
 
______________________________________________________________________________________ 
Name of Insured 
 
_______     ______________     ________________________________      _________________________ 
   Year                 Make                           VIN                                 Title Number          
 
 
Upon submission of an application for a certificate of destruction, the above named company agrees to 
indemnify and hold the Department of Highway Safety and Motor Vehicles and its officials and employees 
harmless from and against any claims, demands, costs, damages, and liabilities resulting from or arising out 
of disputes brought by the insured(s) involving the validity of the electronic signature on the applicable form 
HSMV 82053 for the above described vehicle. 
 
Under penalty of perjury, I declare that I have read the foregoing document and that the facts stated 
in it are true. 
 
 
Signature of Insurance Company’s authorized agent: ____________________________________________ 
 
 
Printed Name of Insurance Company’s authorized agent:  ________________________________________ 
 
NAIC Code: ____________________________________ 
 
 
Authorized Agent’s Title: __________________________ Date signed: _____________________________ 
 
 
 
HSMV 82052 - 10/12         www.flhsmv.gov