North Carolina Department of Transportation
Division of Motor Vehicles
Liability Insurance Unit
D.The certificate of insurance shall be on a form approved by the Commissioner of the North Carolina Division of Motor Vehicles. The form shall be designated an FS-1 and shall reflect the following:
Name and address of the registered owner
Name of the insurance company and code number
Date of birth of registered owner, if available (non-fleet policies) Drivers license number of registered owner, if available
Year, make, and identification number of vehicle Effective date of policy
Date prepared
Signature of facsimile signature of authorized representative of insurance company (may be pre-printed or stamped)
IV. Authorization
A.An agent representing an insurance company may issue the FS-4 or FS-1 if authorized to do so by the company.
FORMS FS-4 and FS-1: Media / Field Requirements (Paper)
Media Requirements for Paper Forms
Paper forms will no longer be scanned with the AEG PFL 6150 Form Reader. Please disregard previous requirements regarding paper, opacity, mechanical properties, paper edges, cut size and ink. Paper forms are to
conform to the design for Forms FS-4 and FS-1 included in this packet (page 8), including the size requirement of 7”w x 4 ¼”h per form. Certain items of text that appeared on the previous forms have been eliminated from the
new layout – this text may be included at your discretion but must not affect the 7 x 4 ¼ size requirement. The new forms have been designed so that 2 forms will fit on one 8 ½”w x 11”h sheet of paper for the purpose of faxing.
Any forms not computer-generated must be typed.
See the end of the document for an example of each form.
Field Requirements for Paper Forms
1.Vehicle Year:
a.For both personal and business operating a single vehicle: Enter 4 digit year of manufacture (yyyy).
b.For business operating a schedule of vehicles: Leave blank and enter each vehicle year separately on an attached schedule, along with the corresponding VIN and vehicle make.
c.For dealership, transporter, or drive-away: Leave blank.
2.Vehicle Make:
a.For both personal and business operating a single vehicle: Enter first 4 letters of vehicle make (Ex.
“Chev”, “Buic”).
b.For business operating a schedule of vehicles: Leave blank and enter each vehicle year separately on an attached schedule, along with the corresponding VIN and vehicle year.
c.For dealership, transporter, or drive-away: Leave blank.
3.Vehicle Identification Number (VIN):
a.For both personal and business operating a single vehicle: Enter vehicle identification number obtained from vehicle registration card or from dashboard of vehicle.
b.For business operating a schedule of vehicles: Enter „See Attached Schedule‟ and enter each VIN separately on the attached schedule.
c.For dealership, transporter, or drive-away: Enter „Garage Liability Policy‟.