Form 466 - State Of Alaska - Division Of Motor Vehicles - Certificate Of Insurance
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1STATE OF ALASKA - DIVISION OF MOTOR VEHICLES
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CERTIFICATE OF INSURANCE
CRASH
INFORMATION
Crash Date:
Location:
Name:
Date of Birth:
License:
State:
DRIVER
Mailing Address:
Street or Box:
City:
State:
Zip:
Name:
Date of Birth:
License:
State:
OWNER
OF
Mailing Address:
VEHICLE
Street or Box:
City:
State:
Zip:
VEHICLE
Year:
Make:
Model:
License Plate:
VIN:
Was an automobile liability policy in effect covering this crash?
YES
NO
Name of Insurance Company:
Policy Number:
INSURANCE
Name and
From
To
Address of
Policy
Policyholder:
Period:
SIGNATURE
Your Signature:
Date:
Do not write below this line. The Division of Motor Vehicles will contact your Insurance Company.
Insurance Verification: If the motor vehicle liability insurance policy listed above was not in effect for the motor vehicle listed at the time of the crash indicated
above, the insurance company is to complete the following and return this form to the Division of Motor Vehicles at the address listed on the reverse of this form.
If indicated coverage was in effect at the time of the accident, no action is required.
REASON FOR DENIAL :
Policy Expired Before Crash
Policy Number Given is Incorrect
Lapse in Policy
Policy Effective After Crash
Driver Not Covered on Policy
Other __________________________
Signature of Authorized Representative ______________________________________________ Date _______________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
CUT ON LINE ABOVE. RETURN TOP PORTION ONLY.
MANDATORY INSURANCE AND FINANCIAL RESPONSIBILITY NOTICE
If the actual or estimated damages of any one person's property involved in the crash exceeds $501.00, or if there
is any personal injury or death, you are subject to the Alaska mandatory insurance and financial responsibility
laws. The mandatory insurance laws require you to file proof of insurance with the State of Alaska. Failure to do
so will result in the suspension of your driver's license.
The financial responsibility laws require a person to show financial responsibility by one of the following methods:
(1) an automobile liability insurance policy in effect at the time of the crash; (2) a release of liability; (3) a
settlement agreement and proof of future financial responsibility (SR22 insurance); (4) a deposit of security and
proof of future financial responsibility (SR22 insurance); (5) a finding of no liability by the court in a civil action (a
finding of not guilty of a traffic citation does not apply). Failure to show financial responsibility by one of the listed
methods will also result in the suspension of your driver's license for a period of 3 years if there is a possibility
you are liable.
After any suspension you must show future financial responsibility (SR22 insurance), and pay a reinstatement fee
of $100.00 to $500.00, in addition to the fee for the license being requested, to have your driving privileges
restored. A notice of suspension returned by the post office because of an incorrect address on your driver
license or DMV records will not invalidate the suspension if the notice was mailed to the last address you provided
to DMV.
IMPORTANT: THE FORM ON THE REVERSE MUST BE FILLED IN AND SENT TO THE DIVISION OF MOTOR
VEHICLES WITHIN 15 DAYS FROM THE DATE OF THE CRASH. A participant's accident report is also required if
the crash was not investigated by a peace officer, and the total amount of damage exceeds $2,000.00, or there was
personal injury.
Mail Completed Form to:
DMV
DMV MAIN OFFICE
P.O. BOX 110221
E-mail:
JUNEAU, AK 99811-0221
JDL@admin.state.ak.us
466 REV. 11/2003
(907) 465-4361
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