Form Tr-95 - Insurance Settlement Affidavit - Kansas Department Of Revenue Page 2
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1
2INSTRUCTIONS
1. At least one of the following conditions must be met:
•
The vehicle owner must be a Kansas resident and have a Kansas title in his or her name;
•
The vehicle was not titled in Kansas, however the insurance policy was written by an agent located and licensed
in Kansas. A law enforcement accident report or an MVE-1 must accompany the insurance settlement affidavit for
salvage title form.
•
The vehicle owner is from out-of-state, vehicle is titled out-of-state and the insurance policy was written out-of-state
but the vehicle was wrecked in Kansas and is still located in Kansas. A Kansas law enforcement accident report must
accompany this form. The accident report will be used as proof the accident occurred in Kansas.
2. This form must be completed in its entirety. If another agency or entity acts as Power of Attorney for an insurance company,
the address of the insurance agency, and not the person acting as Power of Attorney,will be required under the Insurance
Company section of this form.
3. KSA 21-3711 provides that falsifying information on any required document is a severity level 8, non-person felony. KSA
21-3710 deals with forgery; forgery is knowingly and with intent to defraud and is a severity 8 non-person felony. KSA
21-3805 addresses perjury, which is severity level 9 non-person felony.
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Parent category: Financial