Free MV3069 Self-Insurance Certification Application - Wisconsin

SELF-INSURANCE CERTIFICATE APPLICATION
MV3069 2/2009

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Wisconsin Department of Transportation Uninsured Motorist Unit PO Box 7983 Madison, WI 53707-7983

Date Application Received

The undersigned applicant, owner of more than 25 motor vehicles registered in the State of Wisconsin, makes application for a certificate of self insurance under s.344.16 Wis. Stats. The purpose of this application is to enable the Wisconsin Department of Transportation to determine whether the applicant has and will continue to have the financial ability to pay judgments arising out of motor vehicle accidents as provided in the Wisconsin Safety Responsibility Act, Ch. 344 Wis. Stats. and the Wisconsin Administrative Code, Ch. Trans. 100. Any self-insurance certificate issued will be valid for a one-year period and is valid only as specified in s.344.14(2) and s.344.30(4) Wis. Stats. It is specifically not valid for the requirements of s.344.51 and s.344.52 Wis. Stats.
Applicant Name Nature of Business

Address - Principal Office

YES

NO
1. Are you now operating as a self-insurer? If so, how long? 2. Do you have a claims department for investigating and adjusting claims? If not, how are claims investigated and adjusted? 3. Have you set up a reserve fund for accident claims? If so: a) b) Under what caption does it appear on your financial statement? What basis is used for determining reserve requirements?

If not, how do you determine your outstanding liability?

4. Give the following information concerning all motor vehicle accidents in which your vehicles were involved during the past three years.

Accident Year
A. Number of Accidents Personal Injury ............................................................................ Property Damage ........................................................................ Total Number of Accidents ...................................................... B. Number of Claims Personal Injury Settled by Payment ............................................................... Settled Without Payment ........................................................ Open and Pending ................................................................ Total ........................................................................... Property Damage Settled by Payment ............................................................... Settled Without Payment ........................................................ Open and Pending ................................................................ Total ...........................................................................

Accident Year

Accident Year

Number of accidents for which no claims were made 1

Accident Year
C. Payments on Claims Personal Injury ............................................................................ Property Damage ........................................................................ Total ................................................................................. D. Reserves for Pending Claims Personal Injury ............................................................................ Property Damage ........................................................................ Total .................................................................................

Accident Year

Accident Year

YES

NO
5. Are any automobile liability judgments open and unsatisfied? If so, how many? What is the total amount involved? Are any other judgments open and unsatisfied? If so, how many? What is the total amount involved? 6. Is your company a self-insurer under any other phase of your business? If so, give specifics.

Self-Insurance Verification All motor vehicles registered to self-insured certificate holders are covered under the self-insurance certificate when the vehicle is involved in an accident. When a report of an accident involving a self-insured vehicle is received, the Wisconsin Department of Transportation may mail an insurance verification notice to the self-insured owner. The Department will assume that the operator of the vehicle is also covered under the certificate unless the self-insured notifies the Department otherwise within 30 days of the mailing of the insurance notice to the self-insured.
Address to which the self-insurance verification notice should be mailed

ATTACH CURRENT FINANCIAL STATEMENT
Submitted By

Individual
Principal Office(s) Location(s)

Partnership
Business Area Code - Telephone Number

Corporation
2

This application for self-insurance covers the vehicles listed below and/or on attached riders and such additional new or used vehicles purchased or traded in the interim.
Year of Manufacture Vehicle Make Vehicle Type Vehicle Model Vehicle Identification Number Vehicle License Number

3

Give the following additional information:
A. Financial Institutions in which company has accounts
Name Address

Name

Address

Name

Address

B. Amount of Insurance on the following
Inventories Plants

C. Attach statement of Profit and Loss to date of Balance Sheet. D. Date incorporated or established E. Are any assets pledged to secure notes, loans, or mortgages payable?

Yes

No

If yes, list below.

F. If you have any Notes or Accounts Receivable or Payable from or to officers or stockholders, give details concerning method and terms of payment.

G. List names of officers or partners of company.

(Officer/Partner Signature)

State of
(Print Name)

) County ) ss. )

(Print Title)

Subscribed and sworn to before me this date:

(Officer/Partner Signature)

(Signature, Notary Public, State Named Above)

(Print Name)

(Print or Type Name, Notary Public, State Named Above)

(Print Title)

(Date Commission Expires)

FOR DIVISION USE ONLY
Financial ability approved and Certificate SI no. issued this date:

(Division of Motor Vehicles Administrator Representative)

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