Condition Of Vehicle After Hurricane Katrina Disclosure Statement Form
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1CONDITION OF VEHICLE AFTER HURRICANE KATRINA
DISCLOSURE STATEMENT
Louisiana Office of Motor Vehicles
1-877-DMV-Line or 225-925-6278
YEAR: _____________
MAKE:_______________________________
VIN:
_____________________________________________________
In accordance with Louisiana R.S. 32:702, when, as a result of an insurance settlement, a motor
vehicle is declared to be a total loss, the insurance company, its authorized agent, or the vehicle
owner must apply for a salvage title within thirty (30) days from the settlement of the property
damage claim. A salvage title is issued in the name of the insurance company, its authorized
agent, or vehicle owner who may dismantle, sell, rebuild, or restore the salvaged vehicle.
The undersigned
registered owner confirms
that the vehicle stated above:
Was not in Katrina disaster area
Minor Water Damage ____%
Sustained NO Physical damage
Minor Physical damage ____%, no total loss
Sustained NO Water damage
Other ________________ (explain reason)
Upon signature and acknowledgement from the insurance company, the vehicle owner hereby
requests the LA Office of Motor Vehicles to remove the “ST/SK” salvage flags from the described
vehicle record.
_____________________________________________________________________________
Printed Name & Signature of Registered Owner
Date
//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
The undersigned
authorized agent/representative for the insurance company confirms
that an
agreement or settlement has been made with the insured, as follows:
Claim was initiated but closed with no settlement being made
Settlement made, vehicle sustained minor damages or less than total loss (attach proof of loss
statement)
Claim was closed at the request of the insured – No settlement
Insured did not have appropriate coverage – Liability only
Other: __________________________________________
INSURANCE COMPANY: ________________________________________ CLAIM #________
_____________________________________________________________________________
Printed Name/Signature of Authorized Agent/Representative
Daytime Phone Number
DISCLAIMER: Upon removal of the ST/SK flags, the Office of Motor Vehicles or its authorized agents
assumes no responsibility or liability for any vehicle found to have actually sustained damages to
the extent of a total loss or found to have sustained water damage. The LA Certificate of Title will
not be branded to indicate salvage (total loss) or water damage.
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