090426_DMV Manual Courtesy Reporting Request | California Low Cost Auto Insurance Program

California Low Cost Auto Insurance

DMV Manual Courtesy Reporting Request
This request form is intended only for active California Low Cost Auto Insurance Program insureds needing a manual courtesy insurance reporting submitted to DMV.

Please complete all fields accurately. Incorrect or mismatched information may delay or prevent DMV processing.

Please allow approximately 2–3 business days for processing once submitted.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Has your vehicle registration already been suspended by DMV?
- Have you already paid the DMV reinstatement fee (~$14)?
- DMV Reinstatement Fee Required
  
  You must first pay the DMV reinstatement fee before submitting a request for manual insurance reporting.
  
  For more instructions on how to complete this: CLICK HERE
  https://www.pacificinsuresme.com/registrationsuspension.html
  
  After payment has been completed, please return and resubmit this form.
- Important Notice
  
  By proceeding, you certify under penalty of perjury that the DMV reinstatement fee has already been submitted.
  
  You understand that if the reinstatement fee has not actually been paid, DMV may reject or ignore the manual insurance reporting request.
  
  If the fee has already been paid, no further action should be needed after submission other than allowing DMV time to process and update their records.
  
  We will attempt to notify you by text message and/or email once DMV confirms receipt and processing.
- Important Notice
  
  By proceeding, you certify under penalty of perjury that the vehicle registration has not already been suspended by DMV.
  
  You understand that if the registration has already been suspended and the required DMV reinstatement fee has not been paid, DMV may reject or ignore the manual insurance reporting request.
  
  If the registration is not currently suspended, then no further action should be needed after submission other than allowing DMV time to process and update their records.
  
  As a courtesy, we will attempt to notify you by text message and/or email once DMV confirms receipt and processing of the insurance reporting request.
- Date of Suspension (Optional if not suspended)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Vehicle License Plate Number
- Vehicle Year
- Vehicle Make
- Vehicle Model
- Last 5 Digits of VIN
- Reference Number / Policy Number
Should be Empty: