Insurance Company Motor Vehicle Release Statement

In the case of wanting to release a motor vehicle to an owner, the following form has to be completed and submitted.

Extracted Text for Proper Search

STATE OF FLORIDA 	 	DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES 	 	DIVISION OF MOTORIST SERVICES  	 	
Insurance Company Motor Vehicle Release Statement 	 	
(This form must be completed by the insurance company and  
provided to the appropriate independent entity/business.) 	
 	
Pursuant to s. 319.30(9)(a), Florida Statutes, this completed and signed form authorizes the entity/business 
named in section 3 to release the motor vehicle described below to the owner named in section 1. 	
 	
SECTION 1 (Owner-Insured/Vehicle Information) 
 Date of Release to Owner: 
 
 
Name of Owner:                                               
 Name of Insured (if different from owner): 
Mailing Address of Owner:  Street:                                         
 
Apt. #:                             City: 
 
State:                              Zip:                                             Mailing Address of Insured (if different from owner):   	 Street:                                           
 
Apt. #:                             City: 
 
State:                              Zip:                                             	
Year:  Make:  Vehicle Identification Number:  Title Number: 	
 	
SECTION 2 (Insurance Company Information) 	 	
Name of Insurance Company:  Telephone Number: 
Mailing Address of Insurance Company: 
City: State: Zip: 
Policy Number of Insured:  Claim Number of Insured: 	
 	
SECTION 3 (Independent Entity/Business Information) 	 	
Name of Entity/Business:  Telephone Number: 
Mailing Address of Entity/Business: 
City: State: Zip: 	
 	
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true. 	 	
Signature of Authorized Insurance Agent  Printed Name of Insurance Agent 	
 
 
HSMV 82089 S (07/11)                                                               www.flhsmv.gov