Fillable Power of Attorney Or Complete this form to (Plymouth Rock Assurance)

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Power of Attorney Or Complete this form to (Plymouth Rock Assurance)

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CLAIM NUMBER
(12-digit number)
To be completed by the vehicle owner.
I hereby appoint a representative of Plymouth Rock Assurance Corporation of 695 Atlantic Avenue, Boston, Massachusetts, as my
Attorney-in-Fact to apply for Certified, or duplicate Certificate of Title (and/or) to transfer one:
Vehicle: Vehicle Identification Number:
and for said purpose(s) to sign my name and do all things necessary to this appointment.
✘
Policyholder Signature (To be signed in the presence of a Notary Public.) Driver’s License Number
Make and Model
Power of Attorney
Additional form on next page
YOUR SIGNATURE MUST BE NOTARIZED.
Please bring this form to a Notary Public. Sign on the line above in their presence and have your signature notarized.
State of: County of:
On this day of , 201 , before me, the undersigned notary public, personally appeared
, proved to me through satisfactory evidence of identity, being in this
instance , and acknowledged to me that he/she signed the foregoing
voluntarily and for its stated purpose.
Notary Public Signature:
✘
My Commission Expires: / /
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, have your signature notarized before mailing
the form to Plymouth Rock’s Claims Department at the
address provided at the end of the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form and have your signature
notarized before mailing the form to Plymouth Rock’s Claims
Department at the address provided at the end of the form.
Or
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
CLAIM NUMBER
(12-digit number)
To be completed by the vehicle owner.
Federal law requires you to state the mileage shown on the odometer upon transfer of ownership. An inaccurate or untruthful statement
may make you liable for damages and attorneys’ fees to your transferee, and for civil or criminal penalties (49 USCA §§ 32701 et seq.).
I, , owner of state that the odometer of the
vehicle described below now reads miles.
Vehicle: Vehicle Identification Number (VIN):
Check the following statements, only if applicable.
¡
I hereby certify that to the best of my knowledge, the odometer reading as stated above, reflects the actual mileage of the
vehicle described.
¡
I further state that the actual mileage differs from the odometer reading for reasons other than odometer calibration error and
that the actual mileage is unknown.
¡
I further state that the mileage shown on the odometer is in excess of 99,999 miles.
✘
/ /
Seller’s Signature Date
This section to be completed by Plymouth Rock Assurance
Buyer’s First and Last Name:
Street Address: City: State: Zip Code:
✘
Buyer’s Signature (Receipt of Copy Acknowledged)
Mileage Statement
First and Last Name Year, Make and Model of the Vehicle
Number of Miles
Make and Model
Claims Department
Plymouth Rock Assurance Corporation, PO Box 9112, Boston, MA 02112-9112
Return This
Form To
Thank you.
All Rights Reserved ©2012 Rev_02_12
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, mail the form to Plymouth Rock’s Claims
Department at the address provided at the bottom of
the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form. Then mail the form to
Plymouth Rock’s Claims Department at the address provided
at the end of the form.
Or
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
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Power of Attorney Or Complete this form to (Plymouth Rock Assurance)

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Completed 3 August 2021

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