Free MV3128 Installment Agreement to Pay Accident Damages - Wisconsin


File Size: 34.7 kB
Pages: 1
Date: February 18, 2009
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 346 Words, 2,354 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/drivers/forms/mv3128.pdf

Download MV3128 Installment Agreement to Pay Accident Damages ( 34.7 kB)


Preview MV3128 Installment Agreement to Pay Accident Damages
INSTALLMENT AGREEMENT TO PAY ACCIDENT DAMAGES
MV3128 2/2009

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Wisconsin Department of Transportation Uninsured Motorist Unit PO Box 7983 Madison, WI 53707-7983 Telephone: 608-266-1249 Facsimile (FAX): 608-267-0606 E-mail: [email protected]

Accident Date Uninsured Name and Address

Accident File Number Name and Address of Party Receiving Payments - Recipient

Damaged Property Owner Name Injured Person(s) Included in Settlement

Damaged Property Amount

$
Injuries Amount

$

PAYMENT DATES
First Last

INSTALLMENTS
Number of Payments Monthly Amount

Total Settlement 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that the uninsured is in default on the agreed payments, the uninsured's operating/registration privileges will be withdrawn as required under the Safety Responsibility Law.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)

If an insurance company representative signs this agreement, that representative's signature certifies that their insured has been compensated for the insured's damages/injuries.

(Insurance Company Representative Signature- If Applicable)

(Date)

(Title)

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