SR22 Insurance Certification Form

SR22 INSURANCE CERTIFICATION FORM

WHEREAS

WHEREAS, Insurer Name: is authorized to write and issue motor vehicle liability insurance and is licensed to transact insurance in the jurisdiction identified below; and

WHEREAS, Policyholder Name: holds or will hold the policy identified below for the purpose of establishing proof of financial responsibility as required by law; and

WHEREAS, the undersigned insurer certifies under penalty of perjury that the coverage described herein complies with the applicable statutory requirements for financial responsibility and that the insurer will notify the appropriate motor vehicle authority in accordance with the notice provisions stated below.

CERTIFICATION DETAILS

Policy Number:    Policy Effective Date:    Policy Expiration Date:

Coverage Limits (select or state amounts): Bodily Injury per Person: ; Bodily Injury per Accident: ; Property Damage:

Driver License No.:    Driver DOB:

Continuous Coverage Required:    If checked, insurer shall maintain continuous filing and notify the appropriate motor vehicle authority of any lapse or termination in accordance with the notice provisions below.

NOTICE OF CANCELLATION / TERMINATION

The insurer certifies it will provide notice of cancellation or nonrenewal to the motor vehicle authority and to the named insured as required by statute. Required notice period to motor vehicle authority (in days):

Reason for potential termination (if known):

SCOPE OF WORK

Describe the scope of the insurer's certification obligations and any specific instructions or endorsements to be filed with the motor vehicle authority.

PAYMENT TERMS

The policyholder agrees to pay premiums, fees, and any administrative charges associated with issuance and maintenance of this SR22 filing. Premium Amount: .

Late Payment Fee (if any): . Nonpayment may result in cancellation of the policy and notification to the motor vehicle authority as required by law.

TERM AND TERMINATION

Coverage Start Date:    Coverage End Date (if applicable):

Either party may terminate this certification in accordance with the notice provisions set forth herein and in compliance with applicable statute. Required notice to other party for termination (days):

CONFIDENTIALITY

All information exchanged in connection with this certification that is reasonably designated as confidential, including policy terms, personal data of the insured, and claims history, shall be treated as confidential by the receiving party and shall not be disclosed except to the extent required by law, regulation, or lawful order of a competent authority.

GOVERNING LAW

This certification and any disputes arising out of or related to it shall be governed by the substantive laws of the state of: without regard to conflict of law principles.

ENTIRE AGREEMENT

This document, together with any attached declarations and endorsements referenced herein, constitutes the entire agreement between the insurer and the policyholder with respect to the SR22 certification and supersedes any prior agreements, understandings, or communications related to this certification.

CERTIFICATION AND AUTHORIZATION

By signing below, the insurer certifies under penalty of perjury that the information provided in this SR22 Insurance Certification Form is true and correct to the best of its knowledge and that the insurer is authorized to file this certification on behalf of the insured. The policyholder acknowledges receipt of this certification and authorizes release of necessary information to the appropriate motor vehicle authority.

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