Free T341 Evaluation of Property Damage - Wisconsin

Wisconsin Department of Transportation
www.dot.wisconsin.gov

Clear Form
DIVISION OF MOTOR VEHICLES Accident Records Unit PO Box 7919 Madison, WI 53707-7919 Telephone: 608-266-8753 Facsimile (FAX): 608-261-8201 E-mail: [email protected]

EVALUATION OF PROPERTY DAMAGE
T341 T511 3/2009 (Replaces MV3657) P7614070

Use this form ONLY if the DMV Accident Records Unit directs you to use it.

Accident Number: Accident Date: Accident Location: On Street/Highway: At Street/Highway: Veh. Operator/Owner: Due Date:

_

Our records show that your property was damaged in the above accident and that one of the motorists may not have insurance. This form may assist you and/or your insurance company to recover damages. Before you have the certification below completed, please answer the following: ___ Yes ___ No 1. Was a motorist without insurance involved in the accident? ___ Yes ___ No 2. Did the motorist without insurance cause the accident? ___ Yes ___ No 3. Does the motorist without insurance still owe you OR your insurance company for your property damage? ___ Yes ___ No 4. Were your property damages $1,000 or more OR were you (the property owner) listed as injured on the accident report? If you answered "NO" to ANY of these questions, please do NOT return this form. If you answered "YES" to ALL FOUR (4) questions, please read the BACK of this form, have the form completed by a qualified evaluator and returned. PLEASE DO NOT COMPLETE OR SIGN THIS FORM YOURSELF. Damage estimates or bills are NOT acceptable in lieu of a properly completed and signed evaluation. CERTIFICATION OF PROPERTY DAMAGE Description of item(s) evaluated Name and address of owner of item(s)

1. Total property damage resulting from the above accident: 2. Do the repair costs exceed the value of the property? 3. If YES, give approximate fair market value of the property prior to the accident:

$ ____________ ___ No ___ Yes $ ____________

I am aware that this certification will be used by the Department of Transportation to evaluate the property damage resulting from the above accident. To the best of my knowledge the damage amount does not include damages done before or after the above accident. I certify that the above damage amount, evaluated by me, is a true and correct estimate.
(Firm Name) (Address) (City, State, Zip Code) (Evaluator Signature) (Evaluator Title) (Area Code - Telephone Number) (Date)

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Examples of Evaluators who may complete the Certification portion of the form: * Authorized claims representatives from insurance companies; * Authorized technicians skilled in the repair of the property, which was damaged: * Carpenters * Construction Company Contractors * Cyclist Repair Shops * Damage Adjusters or Appraisers * Electricians * Government (city, county, state) * Landscapers * Railroad Companies * Sign Companies * Utilities (power companies, telephone companies, etc.) Who may NOT complete the Certification portion of the form: * You (property owner) * Insurance Agents * Trucking Companies (unless there is only trailer damage, and your company repairs the trailer. A work order
for the repairs must accompany this completed form.)
Damage estimates or bills are NOT acceptable in lieu of a properly completed and signed evaluation. How will the completed form be used? The completed form is a verification to the Department of Transportation of the amount of property damage resulting from this accident. No action can be taken unless this form is properly completed and returned by the due date indicated on the front side of this form. The motorist without insurance may be required to: * Show proof of settlement with you; OR * Deposit security with our department (you will be notified if security is deposited); OR * Lose their driving and/or registration privileges for one year. What can you do? The motorist without insurance often complies with the Safety Responsibility Law. If they do not comply, you
may pursue your claim:
* In small claims court, if the claim is $5,000 or less; OR * In circuit court, if the claim is over $5,000. If the court decides the uninsured owes $500 or more, you may request the court to certify the judgment
to our Department under s.344.05 Wis. Stats. The uninsured will lose their operating and registration
privileges until the judgment is paid or for a maximum of 20 years.
Questions? If you have questions or need more information, please contact the Accident Records Unit at the address
or telephone number listed on the front of this form.


T511

3/2009

P7614070