Buyer's acknowledgement of physical-damage coverage required by the retail installment contract
I acknowledge that my retail installment contract requires the vehicle described below to be kept continuously insured against physical damage, including comprehensive, collision, and fire-and-theft loss, for the entire term of the contract. I have arranged that coverage with the insurance company identified below and have asked my agent to record the lienholder's interest in the vehicle and to endorse the policy with a standard loss-payable clause naming the lienholder.
I understand that if the required coverage is not obtained, or if it lapses at any time during the term of the contract, the lienholder may purchase coverage protecting only its own interest in the vehicle. I authorize the lienholder to add the cost of that coverage, together with any related finance charges, to the unpaid balance of my contract.
| Year | 2019 | Color | BLACK |
|---|---|---|---|
| Make | SAMPLE | Body Style | 4DR |
| Model | DEMO TRUCK | VIN | 1SAMPLEVIN0000001 |
| Name | JOHN Q SAMPLE |
|---|---|
| Address | 456 EXAMPLE AVE, ANYTOWN, NE 68000 |
| Carrier | Sample Insurance Co. | Agent | SAMPLE AGENT |
|---|---|---|---|
| Policy Number | DEMO-000-000 | Agent Phone | 402-555-0102 |
| Effective From | 05/19/2026 | Agent Address | 789 DEMO BLVD, ANYTOWN, NE 68000 |
| Effective To | 06/15/2026 | Coverage Deductible | $500.00 |
| Coverages | ✕ Fire & Theft ✕ Comprehensive ✕ Collision | ||
Notice: The selling dealer and the lienholder may contact the agent listed above to verify any of the information on this form.