Form Tr-95 - Insurance Settlement Affidavit - Kansas Department Of Revenue
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2KANSAS DEPARTMENT OF REVENUE
INSURANCE SETTLEMENT AFFIDAVIT
(Application for Salvage Title Not Surrendered by Claimant)
VEHICLE DESCRIPTION:
Make
Year
VIN#
_______________________
________
________________________________________________
Fuel Type
Weight
Color
________________________________________________
____
_______
_____________
INSURANCE COMPANY:
Name of Insurance Company
_____________________________________________________________________
_______________________________________________________________________________________________
Location Address
City
State
Zip
___________________________________________________________________ ___________________________
Printed Name of Individual or Business Receiving Settlement
Acceptance Date of Settlement
EVIDENCE TO OBTAIN CERTIFICATION OF TITLE:
Evidence of two (2) written attempts to obtain the certificate of title were made without success is required and must
accompany this document and be submitted with the application for salvage title. The written requests were sent to:
_______________________________________________________________________________________________
Owner’s Printed Name
_______________________________________________________________________________________________
Owner’s Street Address
City
State
Zip
Date of first attempt. (May be included as a condition of a settlement document):
__________________
MM/DD/YYYY
Date of second attempt. (Must be at least 15 days after the first written attempt to obtain title):
__________________
MM/DD/YYYY
CERTIFICATION:
I, the undersigned, authorized agent of the insurance company hereby certify the vehicle referenced in this affidavit has
been wrecked and/or damaged to the extent which requires the vehicle to be designated as a salvage vehicle. A damage
settlement has been accepted by the owner and the company has taken physical possession of the vehicle. The company
attests the vehicle owner has failed to deliver an assigned title to the company, therefore the company has delivered by mail,
in person or by electronic means, 30 days prior to filing this affidavit, two written demands to the owner for the surrender
of an assigned title notifying the owner that failure to comply will result in the company claiming the title to the vehicle. The
company will hold harmless and indemnify the Kansas Division of Vehicles, all officials and employees of the division for any
loss suffered or claims counter to this affidavit resulting from the issuance of the salvage title.
I declare, verify, certify or state under penalty of perjury that, I am an authorized agent of the insurance company listed
herein that is authorized to do business in the State of Kansas. The insurance company accepts and takes all responsibility
for compliance with KSA 58-813 and statutes listed therein as well as requirements listed in the affidavit and will be liable
for any harm resulting from this action.
Authorized Agent’s Signature: _____________________________________________________________________
Hand Printed Name: ___
___
__
______________________________________________________________________
This affidavit was executed on:
____
__
____________________
MM/DD/YYYY
TR-95 (Rev. 1/15)
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