Motor Vehicle Financial Responsibility Forms
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- Melvyn Briggs
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1 Alphabetical Index Forms are listed alphabetically by form title. Important Note: The forms shown herein for each state may not be a complete listing of all the financial responsibility forms that are required for the state. Some forms are not stocked by WOLTERS KLUWER FINANCIAL SERVICES because of their infrequent use (resulting in little demand) or because supplies are available from a state source. The state usage indicated for the various forms was based on the best information we had at the time of publication. You should be guided by individual state requirements. When using Acord Forms, user should be guided by instruction from the Acord Corporation. PAGE MC 1 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
2 MULTI-STATE AAMVA FORMS These forms are based on text suggested by the American Association of Motor Vehicle Administrators (AAMVA) for multi-state application. Numerous states have adopted these forms and such is so indicated in the state listings herein, except as noted for SR-21 and SR-24. SR-23 does not apply in the county of Honolulu. * (C) R1302 A 10/91 SR CERTIFICATE OF INSURANCE (IN ADDITION TO PRINTED APPLICATIONS, THE FOLLOWING STATES ARE CURRENTLY PARTICIPANTS IN AAMVA S SR 22/26 ELECTRONIC APPLICATION FILING: CO, ID, IL, NE, WA, WI, WY) AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY (N) R1303 A 10/91 SR23 NOTICE FOR FLEETS AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IN, LA, MS, MT, ND, NH, NM, NV, OH, OK, OR, RI, SC, TN, TX, VA, WA, WI, WV, WY R1307 A 10/91 SR26 NOTICE OF CANCELLATION OR TERMINATION (IN ADDITION TO PRINTED APPLICATIONS, THE FOLLOWING STATES ARE CURRENTLY PARTICIPANTS IN AAMVA S SR 22/26 ELECTRONIC APPLICATION FILING: CO, ID, IL, NE, WA, WI, WY) AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY R1305 A 10/91 SR24 NOTICE OF CHANGE AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY R1300 A 10/91 SR21 NOTICE OF POLICY (UNIFORM HAS NO INDICATION OF THE STATE USAGE FOR THIS FORM, BUT THERE CONTINUES TO BE A SUBSTANTIAL DEMAND FOR IT AND, THEREFORE, WE WILL MAINTAIN IT AS A STOCK ITEM.) GENERAL USE/STATE SPECIFIC Alabama ACORD50AL 10/07 ACORD50AL(2007/10) ALABAMA INSURANCE IDENTIFICATION CARD R1451 A 07/01 ALABAMA MOTOR VEHICLE INSURANCE R /06 SR-21 PROOF OF LIABILITY INSURANCE - ALABAMA R /01 AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY PAGE MC 2 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
3 TEMPORARY MOTOR VEHICLE INSURANCE Alaska R1355 SR-22 CERTIFICATE OF INSURANCE ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Arizona ACORD50AZ 08/12 ACORD50AZ(2012/08) ARIZONA INSURANCE IDENTIFICATION CARD R1371 D 08/12 ARIZONA MOTOR VEHICLE INSURANCE ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Arkansas ACORD50AR 10/07 ACORD50AR(2007/10) ARKANSAS PROOF OF INSURANCE CARD R1320 C 09/07 R1320C 09/07 AUTOMOBILE INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE R1443 A 08/05 SR10805 MOTOR VEHICLE ACCIDENT REPORT R /01 PROOF OF LIABILITY INSURANCE FOR MOTORBOAT OR WATERCRAFT California ACORD51CA 07/04 ACORD51CA(2004/07) CALIFORNIA EVIDENCE OF LIABILITY INSURANCE ACORD50CA 07/04 ACORD50CA(2004/07) CALIFORNIA INSURANCE R1406 P 09/08 SR10908 CALIFORNIA TRAFFIC ACCIDENT REPORT R /00 COMMERCIAL/FLEET AUTOMOBILE INSURANCE CARD R1331 C 08/91 SR75 EMPLOYER'S INSURANCE CERTIFICATE R1435 A 01/04 REG890AREV597 EVIDENCE OF LIABILITY INSURANCE R1349 B 06/00 SR22SR1P INSURANCE PROOF CERTIFICATE R1332 D 11/91 SR76 NOTICE OF CANCELLATION R1330 G 10/07 SR-26/SR-1PF NOTICE OF CANCELLATION INSURANCE PROOF CERTIFICATE PAGE MC 3 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
4 R1448 A 03/00 PRIVATE PASSENGER AUTOMOBILE INSURANCE CARD R1465 B 10/09 SR19C REQUEST FOR INFORMATION (INSURANCE INFORMATION, UNINSURED MOTORIST CERTIFICATION, PHOTO COPY OF SR1 REPORT) R1469 A 08/10 REG 481 SALVAGE VEHICLE NOTICE OF RETENTION BY OWNER Colorado ACORD50CO 03/07 ACORD50CO(2007/03) COLORADO AUTO INSURANCE R1321 A 07/03 (FOR USE WITH POLICIES ISSUED 7/1/03 OR AFTER) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Connecticut ACORD50CT 01/09 ACORD50CT(2009/01) CONNECTICUT INSURANCE R1311 F 10/13 (PERMANENT) R1317 C 02/01 (TEMPORARY) R1399 A 05/10 INSURANCE (PERMANENT - FOR COMMERCIAL MOTOR VEHICLES) R1325 D 06/06 IRB3613C SPECIAL FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE (NOT AVAILABLE ELECTRONICALLY) GU1327 G 07/09 IRB 3616D SPECIAL NOTICE OF CANCELLATION OR TERMINATION (NOT AVAILABLE ELECTRONICALLY) MC /00 VANPOOL INSURANCE CERTIFICATE Delaware R /91 FR4 01/94 ASSIGNED RISK INSURANCE CERTIFICATE REQUEST R /08 DELAWARE INSURANCE COMMERCIAL/ FLEET R1388 A R1356 A 09/07 FR19 INSURANCE CERTIFICATE R /91 LETTER OF TRANSMITTAL (FOR USE WITH R1350) R /91 LISTING OF VEHICLES INSURED R1359 A 09/07 FR4 09/07 NOTICE OF CANCELLATION OR TERMINATION OF POLICY R /91 FR10490 UNINSURED VEHICLE REPORT District of Columbia ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 PAGE MC 4 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
5 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Florida R /74 AUTOMOBILE INSURANCE BINDER R /71 SR22 06/71 FINANCIAL RESPONSIBILITY FORM ACORD50FL 07/09 ACORD50FL(2009/07) FLORIDA AUTO INSURANCE ID CARD ACORD51FL 07/09 ACORD51FL(2009/07) FLORIDA COMMERCIAL AUTO INSURANCE R1384 A (FOR USE WITH PRIVATE PASSENGER MOTOR VEHICLE INSURANCE POLICY) R /07 FR UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE R /07 FR UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE NOTICE OF CANCELLATION Georgia R /76 AUTHORIZATION TO OBTAIN DRIVER RECORD INFORMATION FROM GEORGIA DEPARTMENT OF PUBLIC SAFETY (FLEET COMMERCIAL RISKS) R1417 B 12/03 FLEET POLICY INFORMATION CARD ACORD50GA 11/08 ACORD50GA(2008/11) GEORGIA INSURANCE POLICY INFORMATION CARD R /03 INSURANCE POLICY INFORMATION CARD NON FLEET R1385 A 01/92 REQUEST FOR MOTOR VEHICLE REPORT R1309 D 10/06 SR22A SAFETY RESPONSIBILITY INSURANCE CERTIFICATE Hawaii R1304 C 01/99 INSURANCE ACORD50HI 01/08 ACORD50HI(2008/01) MOTOR VEH INS ID CARD [HI] (WITH WATERMARK) Idaho R1419 A 07/83 CERTIFICATE OF LIABILITY INSURANCE ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE ACORD50ID 10/07 ACORD50ID(2007/10) STATE OF IDAHO LIABILITY INSURANCE Illinois R /71 SR22A 06/71 (IL) CERTIFICATE R /09 SR-22 PAGE MC 5 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
6 FINANCIAL RESPONSIBILITY CERTIFICATE R /09 SR-26 FINANCIAL RESPONSIBILITY NOTICE OF CANCELLATION OR TERMINATION ACORD50IL 03/07 ACORD50IL(2007/03) ILLINOIS INSURANCE IDENTIFICATION CARD R1341 A 07/96 INSURANCE CARD Indiana R1461 C 03/ R3 AFFIDAVIT OF CURRENT INSURANCE "SR-50" R1432 C 03/ R5305 CERTIFICATE OF COMPLIANCE R /94 CERTIFICATE OF COMPLIANCE (WITH CARE LESSOR'S/EMPLOYER'S AFFIDAVIT) ACORD50IN 11/07 ACORD50IN(2007/11) INDIANA INSURANCE IDENTIFICATION CARD R / /SR21 INDIANA OPERATOR'S PROOF OF INSURANCE/CRASH REPORT ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Iowa ACORD50IA 08/07 ACORD50IA(2007/08) INSURANCE R1437 A 11/08 INSURANCE (AUTO LIABILITY)(STOCKED IN STRIPS OF 3 CARDS, ORDER QUANTITY OF CARDS, NOT NUMBER OF STRIPS) Kansas R /84 SR CERTIFICATE OF INSURANCE R1308 C 07/10 (AUTO LIABILITY INSURANCE) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Kentucky ACORD50KY 01/06 ACORD50KY(2006/01) COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE R1322 D 01/09 COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE Louisiana R1318 A 01/96 PAGE MC 6 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
7 (AUTO INSURANCE) R1497 A 06/11 SR-22 LOUISIANA - FINANCIAL RESPONSIBILITY FORM ACORD50LA 03/08 ACORD50LA(2008/03) LOUISIANA AUTO INSURANCE ID CARD Maine R /71 CERTIFICATE DEALERS R /88 (MOTOR VEHICLE INSURANCE) ACORD50ME 08/07 ACORD50ME(2007/08) MAINE MOTOR VEHICLE INSURANCE Maryland R1403 E 03/09 FR-19 03/09 INSURANCE CERTIFICATION (NOT AVAILABLE ELECTRONICALLY) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Massachusetts ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Michigan R /92 FR NOTICE OF CANCELLATION (FINANCIAL RESPONSIBILITY CERTIFICATE) R /94 FR201A0194 OPERATOR'S POLICY CERTIFICATE R /75 FR OWNERS POLICY CERTIFICATE R1408 B 12/11 STATE OF MICHIGAN CERTIFICATE OF NO FAULT INSURANCE ACORD50MI 08/10 ACORD50MI(2010/08) STATE OF MICHIGAN CERTIFICATE OF NO-FAULT INSURANCE Minnesota ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE R1313 A 01/93 MOTOR VEHICLE INSURANCE AL6875 A 07/00 PAGE MC 7 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
8 MOTOR VEHICLE INSURANCE R /99 SUPPLEMENT TO MINNESOTA MOTOR VEHICLE INSURANCE IDENTIFICATION CARD (SUMMARY OF CRIMINAL PENALTIES) Mississippi R /00 INSURANCE CARD R1450 A 04/13 INSURANCE CARD ACORD50MS 01/01 ACORD50MS(2001/01) MISSISSIPPI INSURANCE Missouri R /71 SR22A 06/71 (MO) CERTIFICATE R /87 (AUTOMOBILE INSURANCE) ACORD50MO 05/07 ACORD50MO(2007/05) MISSOURI AUTO INSURANCE Montana MC /03 MV-5C REV12/03 CANCELLATION OF CERTIFICATE OF INSURANCE - TOW TRUCKS OPERATIONS R1374 (I.D. CARD STOCKED IN PERFORATED STRIPS OF 3 CARDS. ORDER BY QUANTITY OF CARDS DESIRED NOT BY THE STRIP.) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Nebraska ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE R /86 MOTOR VEHICLE LIABILITY INSURANCE CERTIFICATE (I.D. CARD) ACORD50NE 01/07 ACORD50NE(2007/01) NEBRASKA AUTO LIABILITY INSURANCE Nevada R1351 G 07/15 NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE R1456 B 07/15 NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE FOR OPERATOR USE PAGE MC 8 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
9 (New) ACORD52NV 10/15 ACORD52NV(2015/10) NEVADA PERMANENT INSURANCE (WITH WATERMARK) (New) ACORD54NV 10/15 ACORD54NV(2015/10) NEVADA PERMANENT INSURANCE EVIDENCE OF OPERATOR'S POLICY OF LIABILITY INSURANCE (New) ACORD51NV 10/15 ACORD51NV(2015/10) NEVADA TEMPORARY INSURANCE ID CARD (New) ACORD53NV 10/15 ACORD53NV(2015/10) NEVADA TEMPORARY INSURANCE EVIDENCE OF OPERATOR'S POLICY OF LIABILITY INSURANCE R1354 G 07/15 TEMPORARY NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE R1457 B 07/15 TEMPORARY NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE FOR OPERATOR USE New Hampshire ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE New Jersey R1401 C 05/04 INSURANCE R /04 TEMPORARY EVIDENCE OF INSURANCE R1402 D 05/04 TEMPORARY NEW JERSEY INSURANCE New Mexico R /84 (PROOF OF FINANCIAL RESPONSIBILITY) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE New York R1455 A 12/02 MV DMV ODOMETER AND DAMAGE DISCLOSURE STATEMENT R /02 MV104B0502 REPORT OF MOTOR VEHICLE ACCIDENT North Carolina R1379 C 09/99 FS1* CERTIFICATE OF LIABILITY INSURANCE R1310 A 10/89 DL DRIVERS LICENSE LIABILITY INSURANCE CERTIFICATION ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) PAGE MC 9 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
10 INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE R1381 D 09/99 FS-4 NOTICE OF TERMINATION OF LIABILITY INSURANCE MC1720 A 02/06 MVR4CREV NOTIFICATION OF OWNER RETAINED VEHICLE North Dakota R1446 A 09/04 SFN CERTIFICATE OF MOTOR VEHICLE LIABILITY INSURANCE ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE ACORD50ND 08/07 ACORD50ND(2007/08) NORTH DAKOTA INSURANCE Ohio R1467 A 09/10 BMV3303 CRASH REPORT ACORD50 02/07 ACORD50(2007/02) INSURANCE R /95 INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Oklahoma R1319 C 11/09 (OWNER'S AND OPERATOR'S SECURITY VERIFICATION FORM) ACORD51OK 08/09 ACORD51OK(2009/08) OKLAHOMA OPERATORS SECURITY VERIFICATION FORM ACORD50OK 08/09 ACORD50OK(2009/08) OKLAHOMA OWNERS SECURITY VERIFICATION FORM MOTOR VEHICLE COPY Oregon ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 R /93 INSURANCE (I.D. CARD STOCKED IN PERFORATED SHEETS OF 12 CARDS. ORDER BY QUANTITIES OF CARDS DESIRED NOT BY SHEET) AC5011 A 02/07 ACORD50(2007/02) INSURANCE PAGE MC 10 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
11 Pennsylvania R /04 MV6SV0203 APPLICATION FOR CERTIFICATE OF SALVAGE FOR A STOLEN VEHICLE MV6 C 04/14 MV-6 APPLICATION FOR NON REPAIRABLE OR SALVAGE CERTIFICATE R1413 E 08/98 FINANCIAL RESPONSIBILITY R1378 H 02/94 FR40180 NOTICE OF PROPOSED SUSPENSION OF VEHICLE REGISTRATION ACORD50PA 09/07 ACORD50PA(2007/09) PENNSYLVANIA FINANCIAL RESPONSIBILITY Rhode Island R1431 C 01/08 INSURANCE ACORD50RI 01/08 ACORD50RI(2008/01) RHODE ISLAND INSURANCE GU1338 E 09/11 IRB3676 RHODE ISLAND SPECIAL FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE South Carolina R /94 SR 21 FINANCIAL RESPONSIBILITY FORM R /00 MOTOR VEHICLE INSURANCE R /97 PROOF OF FINANCIAL RESPONSIBILITY (STOCKED IN PERFORATED STRIPS OF 3 CARDS. ORDER BY QUANTITY OF CARDS DESIRED NOT NUMBER OF STRIPS) ACORD50SC 01/07 ACORD50SC(2007/01) SOUTH CAROLINA INSURANCE South Dakota R1426 (PERMANENT) R1427 (TEMPORARY) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE ACORD50SD 02/07 ACORD50SD(2007/02) SOUTH DAKOTA INSURANCE Tennessee R1342 A 09/00 JR22 CERTIFICATE (UNDER AGED DRIVERS) R /01 MOTOR VEHICLE INSURANCE CARD R /71 JR23 NOTICE OF CANCELLATION (UNDER AGED DRIVERS) PAGE MC 11 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
12 MC /00 SF-0395 OWNER/DRIVER REPORT ACORD50TN 02/07 ACORD50TN(2007/02) TENNESSEE INSURANCE Texas CR1367 A 10/01 LIABILITY INSURANCE CARD (IN ENGLISH/SPANISH) ACORD50TX 05/15 ACORD50TX(2015/05) TEXAS INSURANCE IDENTIFICATION CARD R1339 C 06/14 TEXAS LIABILITY INSURANCE CARD R1367 B 06/14 TEXAS LIABILITY INSURANCE CARD (ENG/SP) R1454 B 06/14 TEXAS LIABILITY INSURANCE CARD (ENG/SPN) R1369 A 06/14 TEXAS LIABILITY INSURANCE CARD (SPANISH) Utah R1407 B 07/13 (INSURANCE) ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Vermont R /86 (AUTOMOBILE INSURANCE) ACORD50VT 02/07 ACORD50VT(2007/02) VERMONT AUTOMOBILE INSURANCE Virginia R1344 A 04/93 LSD 03 4/93 CERTIFICATION OF RECOVERED STOLEN VEHICLE R /03 FR10197 INSURANCE COVERAGE REPORT ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE R /08 NOTICE OF CANCELLATION OR TERMINATION (FR-46) R /08 UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE (FR-44) Washington ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE ACORD50WM 03/07 ACORD50WM(2007/03) PAGE MC 12 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
13 INSURANCE West Virginia R1346 C 07/12 WV1B CERTIFICATE OF INSURANCE R1360 E 07/12 WV-2B NOTICE OF CANCELLATION OR TERMINATION OF POLICY ACORD50WV 01/14 ACORD50WV(2014/01) WEST VIRGINIA CERTIFICATE OF INSURANCE Wisconsin ACORD50 02/07 ACORD50(2007/02) INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE Wyoming ACORD50 02/07 ACORD50(2007/02) INSURANCE R /92 INSURANCE AC5012 A 02/07 ACORD50(2007/02) INSURANCE (2 AC5011 A 02/07 ACORD50(2007/02) INSURANCE PAGE MC 13 of 13 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:
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