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DMV-SV-1 REV 5/12 West Virginia Department of Transportation Division of Motor Vehicles 1-800-642-9066 www. dmv*wv*gov Salvage Certificate Application Daytime Phone Name Address CITY STREET ADDRESS STATE ZIP Vehicle Information Make Year Style of Body VIN No* Weight or TRUCKS GVW PASSENGER VEHICLE COMPLETE THIS SECTION IF APPLICABLE Requesting NONREPAIRABLE Certificate Odometer Reading Flood Damage 15. 00 FEE Over 75 damaged not to be reconstructed* Fire Damage Salvage NO FEE IS DUE Owner Retention MUST PROVIDE INSURANCE COMPANY NAME INDICATE DAMAGE BY CHECKING THE APPROPRIATE BOX OR LIST PART UNDER OTHER. Front Bumper Grill Assembly Hood Fender - Left Fender - Right Door Front - Left Door Front - Right Door Rear - Left Door Rear - Right Windshield Side Glass - Left Side Glass - Right Rear Glass Roof Panel Qtr* Panel - Left Qtr* Panel - Right Deck Lid Rear Door S/W Rear Bumper Frame Suspension Seats Radio Unit Battery Dash Panel Engine Other Other Includes Boats Campers Cycles and misc* Lienholder Information If required Amount Date LIENHOLDER Applicant Certification I hereby certify under penalty of fines and/or imprisonment that the statements made herein are correct to the best of my knowledge and belief* PRINTED NAME OF INSURANCE COMPANY X ORIGINAL SIGNATURE OF INSURANCE COMPANY REPRESENTATIVE NO COPIES OR STAMPS / DATE A 15. 00 fee accompanies this form unless requesting a NONREPAIRABLE certificate. ANY ALTERATIONS OR ERASURES WILL VOID THIS FORM. dmv*wv*gov Salvage Certificate Application Daytime Phone Name Address CITY STREET ADDRESS STATE ZIP Vehicle Information Make Year Style of Body VIN No* Weight or TRUCKS GVW PASSENGER VEHICLE COMPLETE THIS SECTION IF APPLICABLE Requesting NONREPAIRABLE Certificate Odometer Reading Flood Damage 15. 00 FEE Over 75 damaged not to be reconstructed* Fire Damage Salvage NO FEE IS DUE Owner Retention MUST PROVIDE INSURANCE COMPANY NAME INDICATE DAMAGE BY CHECKING THE APPROPRIATE BOX OR LIST PART UNDER OTHER. 00 FEE Over 75 damaged not to be reconstructed* Fire Damage Salvage NO FEE IS DUE Owner Retention MUST PROVIDE INSURANCE COMPANY NAME INDICATE DAMAGE BY CHECKING THE APPROPRIATE BOX OR LIST PART UNDER OTHER. Front Bumper Grill Assembly Hood Fender - Left Fender - Right Door Front - Left Door Front - Right Door Rear - Left Door Rear - Right Windshield Side Glass - Left Side Glass - Right Rear Glass Roof Panel Qtr* Panel - Left Qtr* Panel - Right Deck Lid Rear Door S/W Rear Bumper Frame Suspension Seats Radio Unit Battery Dash Panel Engine Other Other Includes Boats Campers Cycles and misc* Lienholder Information If required Amount Date LIENHOLDER Applicant Certification I hereby certify under penalty of fines and/or imprisonment that the statements made herein are correct to the best of my knowledge and belief* PRINTED NAME OF INSURANCE COMPANY X ORIGINAL SIGNATURE OF INSURANCE COMPANY REPRESENTATIVE NO COPIES OR STAMPS / DATE A 15. Front Bumper Grill Assembly Hood Fender - Left Fender - Right Door Front - Left Door Front - Right Door Rear - Left Door Rear - Right Windshield Side Glass - Left Side Glass - Right Rear Glass Roof Panel Qtr* Panel - Left Qtr* Panel - Right Deck Lid Rear Door S/W Rear Bumper Frame Suspension Seats Radio Unit Battery Dash Panel Engine Other Other Includes Boats Campers Cycles and misc* Lienholder Information If required Amount Date LIENHOLDER Applicant Certification I hereby certify under penalty of fines and/or imprisonment that the statements made herein are correct to the best of my knowledge and belief* PRINTED NAME OF INSURANCE COMPANY X ORIGINAL SIGNATURE OF INSURANCE COMPANY REPRESENTATIVE NO COPIES OR STAMPS / DATE A 15. 00 fee accompanies this form unless requesting a NONREPAIRABLE certificate. ANY ALTERATIONS OR ERASURES WILL VOID THIS FORM.