Collector Vehicle Qualification Form Applicant Copy

Collector Vehicle Qualification Form
IMPORTANT: The qualification process applies only to
passenger vehicles and light trucks. For complete information
about the Collector Vehicle Program and its requirements,
please visit mpi.mb.ca.
Instructions
The Collector Vehicle Program offers special insurance coverage to customers who own collector vehicles. To be eligible, your vehicle must
meet certain criteria (see Declaration) and you must qualify your vehicle.
Please visit the Manitoba Association of Automobile Clubs (MAAC) website at www.maac.cc for information on how to set up a qualification
appointment with a MAAC representative. If you prefer a qualification appointment with Manitoba Public Insurance or you have questions please
call 204-985-7000 or toll-free 1-800-665-2410.
You must complete and sign both copies of this form (Applicant Copy and Qualifier Copy) and take both to your qualification
appointment. Once you have qualified, you must visit an Autopac agent in person and present the completed and stamped Applicant
Copy for processing.
All qualified customers receive a unique collector vehicle licence plate. Personalized plates are also available. To request a personalized
collector vehicle plate or to transfer an existing personalized message to a collector vehicle plate, please complete and submit a Collector
Vehicle Licence Plate Application form. Visit mpi.mb.ca for an application form.
Registered Owner Information
Declaration
Driver’s Licence Number
By submitting this application I declare that my vehicle
meets each of the following requirements of the Collector
Vehicle Program:
or
Manitoba Public Insurance
Customer Number
Surname
Given Name(s)
Address
City or Town
Postal Code
• is at least 25 years old
• is a passenger vehicle or light truck
• has a value of at least $5,000, and
• is used for ‘Pleasure’ only under Basic Autopac
(i.e. not used for regular commuting)
I understand and accept that qualifying my vehicle for the
Collector Vehicle Program in no way implies an Actual Cash
Value (ACV) for my vehicle.
Daytime Telephone Number
Vehicle Information
Signature of Registered Owner
Vehicle Identification Number (VIN)
Year Make
Date
Model
Current Licence Plate
Office use only
Name of MAAC or Manitoba Public Insurance Representative
Signature
Date
This form is valid for one year from date of issuance.
Applicant Copy
Collector Vehicle Qualification Form
IMPORTANT: The qualification process applies only to
passenger vehicles and light trucks. For complete information
about the Collector Vehicle Program and its requirements,
please visit mpi.mb.ca.
Vehicle Information
Declaration
I consent to the collection of this information by the
authoring service organization (MAAC) and its disclosure to
Manitoba Public Insurance for the purpose of qualifying my
vehicle for participation in the Collector Vehicle Program.
Vehicle Identification Number (VIN)
Year Make Model
Current Licence Plate
Signature of Registered Owner
Date
Office use only
Approved
Name of MAAC or Manitoba Public Insurance Representative
Signature
Denied
Date
This form is valid for one year from date of issuance.
Qualifier Copy