Reset Form
Form 78-032-18-8-1-000 Rev (06/18)
MISSISSIPPI
APPLICATION FOR A SALVAGE CERTIFICATE OF TITLE
INSURANCE COMPANY
FEE $9.00
FORM MUST BE TYPED OR COMPUTER PRINTED AND CAN ONLY BE USED
WHEN THE INSURANCE COMPANY IS UNABLE TO OBTAIN THE PROPERLY
ENDORSED TITLE AFTER DISBURSING A TOTAL LOSS SETTLEMENT
I, the undersigned, certify that the referenced vehicle has been declared a total loss and
the owner of the vehicle has elected not to produce Certificate of Title and one of the
following applies:
Salvage
Junk
I, the undersigned, further certify that documentation described below has been sent to
owner of said vehicle and copies are attached:
• Two (2) written attempts to the owner to obtain the current certificate of title
• A letter of request for a salvage title
• Proof the Lienholder’s Interest was protected
VIN Number: __________________________________________________________________________
Make: _____________________________ Model: __________________________ Year: __________
Owner’s Name: ______________________________________________ Claim #:___________________
Insurance Company Name: _______________________________________________________________
Street Address: ________________________________________________________________________
City: ______________________________________ State: ______________ Zip: _________________
Authorized Agent’s Name: ________________________________________________________________
Date of Total Loss: ______________________________ Date of Settlement: ______________________
Authorized Agent’s Signature and Position Title
Date
This form must be submitted to the Department of Revenue Motor Vehicle Services
Bureau within 30 days after the total loss settlement has been disbursed. This
form must be completed by the Insurance Company. Any incomplete form will be
rejected.
Phone: 601.923.7200
www.dor.ms.gov
Fax: 601.923.7224
Jackson, MS 39215
Motor Vehicle Services
P.O. Box 1383
Reset Form
Form 78-032-18-8-1-000 Rev (06/18)
MISSISSIPPI
APPLICATION FOR A SALVAGE CERTIFICATE OF TITLE
INSURANCE COMPANY
FEE $9.00
FORM MUST BE TYPED OR COMPUTER PRINTED AND CAN ONLY BE USED
WHEN THE INSURANCE COMPANY IS UNABLE TO OBTAIN THE PROPERLY
ENDORSED TITLE AFTER DISBURSING A TOTAL LOSS SETTLEMENT
I, the undersigned, certify that the referenced vehicle has been declared a total loss and
the owner of the vehicle has elected not to produce Certificate of Title and one of the
following applies:
Salvage
Junk
I, the undersigned, further certify that documentation described below has been sent to
owner of said vehicle and copies are attached:
• Two (2) written attempts to the owner to obtain the current certificate of title
• A letter of request for a salvage title
• Proof the Lienholder’s Interest was protected
VIN Number: __________________________________________________________________________
Make: _____________________________ Model: __________________________ Year: __________
Owner’s Name: ______________________________________________ Claim #:___________________
Insurance Company Name: _______________________________________________________________
Street Address: ________________________________________________________________________
City: ______________________________________ State: ______________ Zip: _________________
Authorized Agent’s Name: ________________________________________________________________
Date of Total Loss: ______________________________ Date of Settlement: ______________________
Authorized Agent’s Signature and Position Title
Date
This form must be submitted to the Department of Revenue Motor Vehicle Services
Bureau within 30 days after the total loss settlement has been disbursed. This
form must be completed by the Insurance Company. Any incomplete form will be
rejected.
Phone: 601.923.7200
www.dor.ms.gov
Fax: 601.923.7224
Jackson, MS 39215
Motor Vehicle Services
P.O. Box 1383
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