Form 5042 - Certification By Insurance Company Of Vehicle Damage

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MOTOR VEHICLE BUREAU
FORM
PO BOX 2076, JEFFERSON CITY MO 65101-0100
5042
(573) 526-3669
CERTIFICATION BY INSURANCE COMPANY OF VEHICLE DAMAGE
(REV. 8-2010)
This form is to be used by insurance companies/owners applying for an Original or Salvage Missouri
Certificate of Title as the result of a settlement of a claim for loss due to damage or theft.
Insurance company applying for an Original Missouri Certificate of Title on
Year __ __ __ __ Make ___________________ Vin __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
As the result of a settlement of a claim for loss due to damage.
Insurance company applying for a Salvage Missouri Certificate of Title on
Year __ __ __ __ Make ___________________ Vin __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
As the result of a settlement of a claim for loss due to damage or theft.
Owner applying for an Original Missouri Certificate of Title on
Year __ __ __ __ Make ___________________ Vin __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
As the result of a settlement of a claim for loss due to damage or theft.
Owner applying for a Salvage Missouri Certificate of Title on
Year __ __ __ __ Make ___________________ Vin __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
As the result of a settlement of a claim for loss due to damage or theft.
The insurance company is surrendering a salvage title to be redeemed for an original title due to recovery of
a stolen vehicle. A completed 551 inspection form must be submitted. The estimated cost to repair the
damage to the vehicle is 80 percent or less of the pre-damaged fair market value in accordance with Section
301.010 (51) RSMo. The total cost of repairs does not include the cost of repairing, replacing, or reinstalling
inflatable safety restraints, tires, sound systems, or damage as a result of hail, or any sales tax on parts or
materials. The 551 inspection must be completed by the Missouri State Highway Patrol or the St. Louis City
or County Authorization Theft Unit.
STREET ADDRESS OF INSURED OR OWNER
CLAIM NUMBER
CITY
STATE
ZIP CODE
__ __ __ __ __
I understand this certification will be used to apply for an Original or Salvage Certificate of Title in the insurance
company or owner name for this motor vehicle, trailer, or all-terrain vehicle and that any false statements in this
certification will subject me to civil and criminal liability.
I hereby certify under penalty of perjury that all information regarding this request is true and accurate and is
made without intent to defraud.
SIGNATURE OF AUTHORIZED AGENT/OWNER
DATE
__ __ / __ __ / __ __ __ __
MO 860-3026 (8-2010)

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