National Casualty Company
8877 North Gainey Center Drive • Scottsdale, Arizona 85258
AUTOMOBILE MECHANICAL
INSPECTION REPORT
Policy No:
Year Make Model Serial Number
Are the following items in good condition and functional? Please check YES or NO and comment if NO in comments
section.
comments
YES
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1. Speedometer
2. Horn
3. Windows
4. Windshield wipers
5. Mirrors
6. Headlights
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Gross Combined
Weight
NO
CA-STMT-4 (6-96)
Signature of Mechanic
Name of Garage
I hereby certify the answers and statements to the above are correct and are made after inspection of this vehicle by:
12. What is the condition of tires? (If unsatisfactory, indicate which ones and condition.)
13. What is general mechanical condition?
14. Does auto appear to be properly maintained?
15. What is general appearance of body as to paint, upkeep, etc.?
16. In addition to any defects disclosed above, what changes or repairs are necessary to place the auto in safe
driving condition?
Date
YES NO
Attach copies of receipts for completed repairs.
Named Insured:
comments
7. Stoplights
8. Turn signals
9. Emergency flashers
10. Proper connection between
tractor and trailer
11. Steering
12. Brakes
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click to sign
signature
click to edit