Fillable Printable Certificate of Insurance - Alaska
Fillable Printable Certificate of Insurance - Alaska
Certificate of Insurance - Alaska
STATE OF ALASKA - DIVISION OF MOTOR VEHICLES
CERTIFICATE OF INSURANCE
LAW ENFORCEMENT INCIDENT NUMBER:
CRASH
INFORMATION
Date of Crash: City Where Crash Occurred:
DRIVER
Driver
Name: _________________________________ Date of Birth: _____________ License #: _________________ State: ______
Mailing Address: _____________________________________________________________________________________________
Street or Box City State Zip
Daytime Telephone: E-mail:
OWNER
OF
VEHICLE
Driver
Name: _________________________________ Date of Birth: _____________ License #: _________________ State: ______
Mailing Address: _____________________________________________________________________________________________
Street or Box City State Zip
VEHICLE
Year: Make: Model: License Plate #: VIN:
Did you have an automobile liability policy in effect covering this crash? YES NO Policy Number:
Name & Address of Insurance Agent: Phone Number of Insurance Agent:
Name of Insurance Company: Policy Period:
To
Your Signature: Date:
DO NOT WRITE BELOW THIS LINE. THE DIVISION OF MOTOR VEHICLES WILL CONTACT YOUR INSURANCE COMPANY.
Insurance Verification: If the motor vehicle liability insurance policy listed above was not in effect for the motor vehicle listed at the time of
the crash please check the appropriate box below and mail or fax this form to the Division of Motor Vehicles at the address or fax number
listed on the reverse of this form. If indicated coverage was in effect at the time of the crash, no action is required
.
REASON NOT VERIFIED: Insurance information is incorrect No insurance in effect at time of crash
Signature of
Authorized Representative
Date __
MANDATORY INSURANCE AND FINANCIAL RESPONSIBILITY NOTICE
If the actual or estimated damages of any one person’s property involved in the crash exceeds $501, or if there is
any personal injury or death, you are subject to the Alaska mandatory insurance and financial responsibility laws.
The mandatory insurance laws require you to file proof of insurance with the State of Alaska. Failure to do so will
result in the suspension of your driver’s license.
The financial responsibility laws require a person to show financial responsibility by one of the following methods:
(1) an automobile liability insurance policy in effect at the time of the crash; (2) a release of liability; (3) a settlement
agreement and proof of future financial responsibility (SR-22 insurance); (4) a deposit of security and proof of
future financial responsibility (SR-22 insurance); (5) a finding of no liability by the court in a civil action (a finding of
not guilty of a traffic citation does not apply). Failure to show financial responsibility by one of the listed methods
will also result in the suspension of your driver’s license for a period of 3 years if there is a possibility you are liable.
After any suspension you must show future financial responsibility (SR-22 insurance), and pay a reinstatement fee
of $100 to $500, in addition to the fee for the license being requested, to have your driving privileges restored. A
notice of suspension returned by the post office because of an incorrect address on your driver’s license or DMV
records will not invalidate the suspension if the notice was mailed to the last address you provided to DMV.
IMPORTANT: THIS FORM MUST BE COMPLETED IN FULL AND MAILED OR FAXED TO THE DIVISION OF
MOTOR VEHICLES WITHIN 15 DAYS FROM THE DATE OF THE CRASH. A participant’s crash report is required
if the crash was not investigated by a peace officer and the total amount of damage exceeds $2,000, or
there was personal injury.
Mail or Fax Completed Form To: STATE OF ALASKA Fax: (907) 465-5509
DIVISION OF MOTOR VEHICLES
ATTN: DRIVER LICENSING Phone: (907) 465-4361
PO BOX 110221
JUNEAU AK 99811-0221
