Free 48483.FH11 - Indiana

AFFIDAVIT OF CURRENT INSURANCE SR-50
State Form 48483 (R4 / 3-05)

BUREAU OF MOTOR VEHICLES 100 North Senate Avenue Indianapolis, IN 46204 Telephone number: (317) 233-6000

(PLEASE PRINT OR TYPE)

Name of insured

Address (number and street, or Rural Route)

City

State

ZIP code

Driver license number

Name of insurance company

Policy number

Effective date (month, day, year)

Expiration date (month, day, year)

Name of agent (please print)

Agents telephone number

(
Name of insurance companys authorized representative (please print)

)

Written signature of authorized representative

Title

Date (month, day, year)

FRAUDULENT SIGNATURE WILL RESULT IN THE SUSPENSION OF YOUR DRIVING PRIVILEGES!