DS-104 Replacement Plates (eGov)

DS-104 Form / Replacement Plates Request: eGov pages

Data items collected by the eGov Replacement Plates request but not collected by the DS-102 Form;

1. Vehicle Registration Type:

   1. Mission Vehicle

   2. Personal Vehicle

2. Insurance Carrier:

   1. Insurance Company Name

   2. Street Number

   3. Street Name

   4. Street Type

   5. Quadrant

   6. Unit Type

   7. Unit Number

   8. City

   9. State

   10. Zip Code

   11. Insurance Company Phone Number

3. Insurance Broker:

   1. Insurance Broker Name

   2. Street Number

   3. Street Name

   4. Street Type

   5. Quadrant

   6. Unit Type

   7. Unit Number

   8. City

   9. State

   10. Zip Code

   11. Insurance Broker Phone Number

4. Insurance Policy:

   1. Insurance Policy Number

   2. Insurance Policy Start Date

   3. Insurance Policy End Date

   4. Insurance Coverage Type

      1. P/A/P:

         1. Personal Injury per Person Amount

         2. Personal Injury per Accident Amount

         3. Personal Damage per Accident Amount

      2. Combined Single Limit:

         1. Personal Injury and Property Damage per Accident Amount

5. Remark

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