Certificate Of Insurance (Wa) Form - State Of Oklahoma
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1State of Oklahoma
Department of Public Safety
To be completed by insurance agent/carrier only.
W
S
D
Print clearly or type.
recker
ervice
iviSion
CertifiCate of insuranCe (Wa)
Phone:
(405) 425-2295
Fax:
(405)425-2031
I, __________________________________, Hereby certify that ____________________________________
(Authorized Insurance Representative)
(Name of Surety or Insurance Company)
______________________________________________________
____________________________
(Address of Surety or Insurance Company)
NAIC #
has issued to ____________________________________________________ DPS- __________________ -W
________________________________________________________________________________________
(Physical address of wrecker or towing service, not mailing address)
Include the addresses for all storage facilities
providing the insurance coverage required in the rules of the Department of Public Safety for wrecker or towing
services. I further certify that the aforementioned policy will not be cancelled until ten (10) days after the Department
of Public Safety has received written notice of the intent to cancel such policy.
type of insurance
Policy number
Coverage amount
expiration Date
Bodily Injury Liability &
Property Damage Liability
Garagekeeper’s Legal Liability
(Not greater than $500.00 deductible)
On-Hook in In-Tow
(Not greater than $500.00 deductible)
Bailee
(Not greater than $500.00 deductible
All four types of insurance are required for all wrecker classes. Exception: General Class Wrecker Services without storage
are not required to have Garagekeeper’s Legal Liability. Please complete only the sections your company provides.
All wrecker vehicles must be listed. This certificate will replace any previous filing. Use separate sheet if necessary.
Year
Make
VIN
____________
_____________________________
_____________________________________
____________
_____________________________
_____________________________________
____________
_____________________________
_____________________________________
____________
_____________________________
_____________________________________
____________
_____________________________
_____________________________________
_____________________________________________
Company Phone Number: ________________
(Signature of Authorized Insurance Agent/Carrier)
Subscribed and sworn before me this _________ day of ________________________, 20 ______
_____________________________________________
My commission expires: __________________
(Notary Public)
for DePartment of PubliC safety use only
Approved by ___________________________________________ on ____________________, 20 _______
DPS 180WA 0020 102012
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