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.
CLAIM NUMBER
(12-digit number)
To be completed in the event that you incorrectly endorse your Massachusetts vehicle title.
To Whom It May Concern:
I, the undersigned, have incorrectly endorsed my Massachusetts Certificate of Title .
In error, I inadvertently:
¡
signed in the Scrapped, Dismantled, or Destroyed Vehicle section.
¡
defaced, altered, or made erasures in the Assignment of Certificate of Title by Owner of the title.
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signed in the Lien Release section.
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other
.
The proper assignment should have been placed in the Assignment of Certificate of Title by Owner section.
✘
Signature (To be signed in the presence of a Notary Public.)
/ /
Print name Date
Title Number
Title Correction Form
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: / /
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, 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.
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