Fillable Printable Installment Agreement to Pay Accident Damages

Installment Agreement to Pay Accident Damages

INSTALLMENT AGREEMENT TO PAY ACCIDENT DAMAGES

MV3128 9/2002

Wisconsin Department of Transportation

Traffic Accident Section

PO Box 7919

Madison, WI 53707-7919

Telephone: 608-266-1249

Facsimile (FAX): 608-267-0606

E-mail: traffic-accidents.dmv@dot.state.wi.us

Accident Date

Accident File Number

Uninsured Name and Address

Name and Address of Party Receiving Payments - Recipient

Damaged Property Owner Name

Damaged Property Amount

Injured Person(s) Included in Settlement

Injuries Amount

PAYMENT DATES INSTALLMENTS

Total Settlement Amount

First

Last

Number of Payments

Monthly Amount

I/We, the uninsured, agree to pay the above-identified recipient for the property damages/injuries listed above on the following terms:

I/We will make monthly payments to the recipient according to the indicated installments beginning

on the date specified, and on the same date each month thereafter until the total settlement is paid.

A release of liability will be signed by all parties and delivered to the uninsured when the total settlement is paid.

Upon written notice to the Wisconsin Department of Transportation, Traffic Accident Section that the uninsured is in default on the

agreed payments, the uninsured's operating/registration privileges will be withdrawn as required under the Safety Responsibility Law.

Written notice of the delinquent amount may be submitted during the installment period and must be received no later than 30 days

after the final installment is due. There is no provision in the law for reinstatement of privileges by resuming the payments, or by

entering a new installment agreement.

State of

)

) ss

, County

)

Subscribed and sworn to before me this date

(Signature, Notary Public)

(Uninsured Signature)

(Print or Type Name, Notary Public)

(Date Commission Expires)

(Uninsured Signature)

I/We agree to the above settlement and will furnish a valid release upon completion of payments.

(Witness Signature)

(Property Owner/Injured Signature) (Date)

(Witness Signature)

(Property Owner/Injured Signature) (Date)

(Insurance Company Representative Signature- If Applicable) (Date)

(Title)