Insurance SR22 Addition Form

INSURANCE SR22 ADDITION FORM

Insurer / Policy Identification

Insurer Name:

Applicant / Insured Information

Date of Birth:     Driver's License / ID No.:

SR-22 Filing Details

Reason for SR-22 (select all applicable):

DUI / DWI conviction License suspension / reinstatement Failure to maintain insurance

Requested SR-22 Effective Date:     SR-22 Duration Requested (months):

Policy Coverage & Financial Terms

Coverage Limits:

Bodily Injury Per Person — Limit: Bodily Injury Per Accident — Limit: Property Damage — Limit: Combined Single Limit — Amount: Uninsured / Underinsured Motorist — Limit: Medical Payments — Limit:

Deductible:     Current Premium (periodic):

Policy Period Start:     Policy Period End:

Fees and Filing Instructions

SR-22 Filing Fee Charged to Insured:

Insured acknowledges and agrees that the insurer will file an SR-22 certificate with the appropriate state authority on behalf of the insured, and that the insurer may assess administrative fees, additional premiums, or surcharges as a consequence of this filing.

Check to authorize insurer to file SR-22 on your behalf:

Required Documentation Checklist

Please attach or indicate the presence of the following documents:

Current driving record / abstract

Conviction / court disposition documents

Proof of prior insurance (if available)

Exclusions and Limitations

The following coverage exclusions, restrictions or policy conditions apply to any SR-22 related filing. The insurer reserves the right to deny coverage or cancel the policy in accordance with policy terms if the insured fails to comply with premium payment, legal requirements, or material representations:

Designated Beneficiary / Additional Contact (If applicable)

(Optional) If the insured wishes to designate an individual or organization to receive notice related to policy or payment matters, provide details below.

Percentage Allocation (if applicable):

Insured Certification and Authorization

I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that making a false statement or omission may result in denial of coverage, cancellation of the policy, or other legal penalties permitted by law.

I authorize the insurer to file the SR-22 certificate with the appropriate state motor vehicle authority on my behalf. I further authorize the insurer to provide information from this application and subsequent policy records to such authority, and to exchange information with courts or administrative bodies as necessary to maintain compliance with state financial responsibility requirements. I acknowledge that filing an SR-22 may affect my premiums and that additional fees may apply.

By signing below I acknowledge receipt of this SR-22 Addition Form and consent to the insurer's actions as described herein.

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