Al Mli Form – Fill Out and Use This PDF

Insurance Verification Date: <VerificationDate>

PIN #: <PIN>

Registrant Name:<Name>

License Plate: <TagNumber>

<Name>

Vehicle Identification No.: <VIN>

Make: <VehicleMake> Model:<VehicleModel> Year: <VehicleYear>

Was the vehicle identified above insured on the above insurance verification date? Please select ONE response below.

YES

Insurance information must be provided below, OR

NO

The vehicle was operated/registered without insurance on the above insurance verification date. NOTE: The registration

will be suspended. Please refer to mli.mvtrip.alabama.gov for reinstatement instructions and appeal rights, OR

NO

The vehicle was stored/ inoperable on the above insurance verification date. NOTE: The registration will be revoked.

Please refer to mli.mvtrip.alabama.gov for instructions and appeal rights.

Insurance Company Name:

Insurance Co. NAIC Number:

This 5-digit number is required and can be found on your insurance card.

Contact your insurance agent if you are unable to locate this number.

Insurance Co. Street Address:

Ins. Co. City, State, Zip:

Ins. Co. Phone Number:

Policy Number:

Policy Effective Date:

Policy Expiration Date:

Signature:

Date:

<Name>

<Name>

Place

<Address>

Stamp

<City>, <State> <ZipCode>

Here

ALABAMA DEPARTMENT OF REVENUE

MOTOR VEHICLE DIVISION

Mandatory Liability Insurance Unit

P.O. Box 327650

Montgomery, AL 36132-7650