Vehicle Mileage Verification Form (For Insurance Purposes)

This form is used to officially document the current odometer reading of the insured vehicle to ensure accurate policy rating and claim processing. Please complete all sections clearly and accurately.

I. Policy and Vehicle Information

Insurance Company Name:

Policy Holder Name

First Name:

Last Name:

Policy Number:

Vehicle Year:

Vehicle Make:

Vehicle Model:

Vehicle Identification Number (VIN):

Vehicle Registration/License Plate No.:

II. Odometer Reading Verification

This section must be completed by a qualified individual (e.g., mechanic, dealership service representative, authorized inspection agent, or, where permitted, the policyholder).

Current Odometer Reading:

Unit of Measurement:

Date of Reading/Inspection:

Location of Reading/Inspection

Street Address Line 1

Street Address Line 2

City

State/Province

Postal/Zip Code

Odometer Reading History (If available)

	Date of Previous Reading	Previous Odometer Reading	Source of Reading (e.g., Service Record, Inspection)
	A	B	C
1
2
3
4
5

III. Verification Source Details

This section must be completed by the individual or entity who officially verified the current odometer reading.

Name of Verifying Individual:

Title/Role of Verifying Individual:

Name of Business/Entity:

Business/Entity Phone Number:

Business/Entity Email Address:

IV. Required Supporting Documentation

Please attach one of the following supporting documents to this form:

	Description	Upload File
	A	B
1	A clear, date-stamped photograph of the vehicle's odometer showing the VIN (if visible on the dash) and the mileage reading.
2	A recent Service or Maintenance Record (invoice/receipt) from a certified repair facility that clearly states the date and the odometer reading.
3	An official Inspection Report that details the mileage reading.

V. Signature

I, the undersigned, certify that the information provided on this form is true and accurate to the best of my knowledge, and that the odometer reading represents the actual total distance the vehicle has traveled.

I understand that this information will be used by the insurance company for policy administration and in the event of a claim.

Signature of Verifying Individual:

Signature of Policy Holder:

To configure an element, select it on the form.

To add a new question or element, click the Question & Element button in the vertical toolbar on the left.