Form 5317 - Agreement To Pay Judgments

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MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
FORM
301 WEST HIGH STREET - ROOM 470
5317
PO BOX 200
TELEPHONE: (573) 751-7195
JEFFERSON CITY, MO 65105-0200
FAX: (573) 526-7365
AGREEMENT TO PAY JUDGMENTS
(REV 11-2010)
I,
, as a self-insurer pursuant to the provisions of
Sections 303.160 and 303.220, RSMo, do hereby agree, with respect to accidents occurring while
the certificate of self-insurance is in force, to pay the same judgments and in the same amounts
that an insurer would have been obligated to pay under an owner’s motor vehicle
liability policy if such a policy had been issued to
.
Printed Name of Self-Insured
Signed By
Date
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP IN CLEAR AREA BELOW.
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
VISIT OUR WEBSITE AT
DOR-5317 (11-2010)

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