VSA 58 (07/01/2018)
You have elected to keep your vehicle following an insurance claims process for damage. Your insurance company has submitted this form to DMV to report
your vehicle as “owner-retained.” As a result of this report, YOUR CURRENT TITLE AND REGISTRATION HAVE BEEN CANCELLED. You are required to
follow the instructions below for the type of vehicle checked. All required forms are available at any DMV customer service center or at www.dmvNOW.com.
Submit all documents and any applicable fees to:
Virginia Department of Motor Vehicles, ATTN: Vehicle Branding Work Center, P. O. Box 27412, Richmond, Virginia 23269-0001
NOTE: Virginia Code §§ 46.2-624(C), 46.2-1603(D), and 46.2-1603.2(C) require insurance companies to report certain owner-retained vehicles to DMV. DMV is required by
law to cancel the title and registration for any vehicle reported as “owner-retained.” Use of a cancelled title to obtain money or insurance may constitute fraud and may
result in felony charges.
INSURANCE COMPANY AND VEHICLE INFORMATION
INSURANCE COMPANY NAME DATE (mm/dd/yyyy)CLAIM REPRESENTATIVE NAME
INSURANCE CLAIM NUMBER CLAIM PAYMENT DATE (mm/dd/yyyy) CLAIM REPRESENTATIVE TELEPHONE NUMBER
STREET ADDRESS CITY STATE ZIP CODE
VEHICLE OWNER NAME
ZIP CODESTATECITYSTREET ADDRESS
VEHICLE YEAR VEHICLE MAKE TITLE NUMBER STATE
VEHICLE IDENTIFICATION NUMBER (VIN)
ESTIMATED COST OF REPAIR (if required) ACTUAL CASH VALUE PRIOR TO DAMAGE (if required) PERCENT OF DAMAGE (if required)
NOTIFICATION TO VEHICLE OWNER OF REPORT AND REQUIRED PROCEDURES
Insurance company representative must also check the appropriate box in NOTIFICATION TO VEHICLE OWNER section and complete DESCRIPTION OF
DAMAGES section on back of this page.
SSN/FEIN/DMV CUSTOMER NUMBER
NOTIFICATION OF
OWNER-RETAINED AND/OR
WATER-DAMAGED VEHICLE
PURPOSE: Insurance companies use this form to notify the owner of a vehicle (retained from an insurance claims process) about
salvage vehicle laws and procedures. Vehicle owners use this form to comply with DMV procedures for owner-retained
and/or water damaged vehicles.
INSTRUCTIONS: Insurance company completes all sections of this form and provides a copy to the vehicle owner, retains a copy and
sends the original to Vehicle Branding Work Center at the above address. Vehicle owner follows the instructions given
under the box checked in NOTIFICATION section.
Water Damaged Vehicle: Any vehicle that has been damaged by water to such an extent that the insurance company insuring it has paid a claim of
$3,500 or more because of this water damage.
Your insurance company has reported your vehicle as a water damaged vehicle. DMV is required to brand your title as “water damaged.”
Submit: This notification and your current title
Fee: $15 title fee
Salvage Vehicle:
1. Any late model vehicle, defined as the current-year model, and the five preceding model years, or any vehicle whose actual cash value is determined
to be at least $10,000 prior to being damaged, that has been damaged as a result of collision, fire, flood, accident, trespass, or any other occurrence
to such an extent that its estimated cost of repair, excluding charges for towing, storage, and temporary replacement/rental vehicle or payment for
diminished value compensation, would exceed its actual cash value less its current salvage value; or
2. Any vehicle that is determined to be a salvage vehicle by its owner or an insurance company by applying for a salvage certificate for the vehicle,
provided that such vehicle is not a nonrepairable vehicle.
Includes water damage if checked.
Your insurance company has reported your vehicle as a salvage vehicle. DMV is required to replace your title with a salvage certificate unless the
vehicle has been repaired for use on the highways. If repaired, the vehicle must pass a Virginia safety inspection and a DMV salvage examination.
If Not Repaired: If Repaired:
Submit: This notification and your current title Submit: 1. This notification and your current title; and
2. LES 022A, Request for Examination of Rebuilt Salvage Vehicle
Fee: $15 salvage certificate fee Fees: 1. $125 salvage examination fee; and
2. $15 title fee
Nonrepairable Vehicle: Any vehicle that has been determined by its insurer or owner to have no value except for use as parts and scrap metal or for
which a nonrepairable certificate has been issued or applied for.
Your insurance company has reported your vehicle as a nonrepairable vehicle. DMV is required to replace your title with a nonrepairable certificate.
You may not repair your vehicle for use on the highways.
Submit: This notification and your current title
Fee: None
