Alaska Form 466 – Fill Out and Use This PDF

STATE OF ALASKA - DIVISION OF MOTOR VEHICLES

CERTIFICATE OF INSURANCE

					LAW ENFORCEMENT INCIDENT NUMBER:
	CRASH	Date of Crash:			City Where Crash Occurred:
	INFORMATION
								Driver
		Name: _________________________________ Date of Birth: _____________						License #: _________________	State: ______
	DRIVER	Mailing Address: _____________________________________________________________________________________________
			Street or Box			City		State	Zip
		Daytime Telephone:				E-mail:
	OWNER							Driver
		Name: _________________________________ Date of Birth: _____________						License #: _________________	State: ______
	OF	Mailing Address: _____________________________________________________________________________________________
	VEHICLE
			Street or Box			City		State	Zip
	VEHICLE	Year:	Make:	Model:	License Plate #:			VIN:
	Did you have an automobile liability policy in effect covering this crash? YES					NO	Policy Number:
	Name & Address of Insurance Agent:							Phone Number of Insurance Agent:
	Name of Insurance Company:							Policy Period:
								To
	Your Signature:							Date:

DO NOT WRITE BELOW THIS LINE. THE DIVISION OF MOTOR VEHICLES WILL CONTACT YOUR INSURANCE COMPANY.

Insurance Verification: If the motor vehicle liability insurance policy listed above was not in effect for the motor vehicle listed at the time of the crash please check the appropriate box below and mail or fax this form to the Division of Motor Vehicles at the address or fax number listed on the reverse of this form. If indicated coverage was in effect at the time of the crash, no action is required.

REASON NOT VERIFIED:		Insurance information is incorrect	No insurance in effect at time of crash
Signature of
Authorized Representative				Date __

MANDATORY INSURANCE AND FINANCIAL RESPONSIBILITY NOTICE

If the actual or estimated damages of any one person’s property involved in the crash exceeds $501, or if there is any personal injury or death, you are subject to the Alaska mandatory insurance and financial responsibility laws. The mandatory insurance laws require you to file proof of insurance with the State of Alaska. Failure to do so will result in the suspension of your driver’s license.

The financial responsibility laws require a person to show financial responsibility by one of the following methods:

(1)an automobile liability insurance policy in effect at the time of the crash; (2) a release of liability; (3) a settlement agreement and proof of future financial responsibility (SR-22 insurance); (4) a deposit of security and proof of future financial responsibility (SR-22 insurance); (5) a finding of no liability by the court in a civil action (a finding of not guilty of a traffic citation does not apply). Failure to show financial responsibility by one of the listed methods will also result in the suspension of your driver’s license for a period of 3 years if there is a possibility you are liable.

After any suspension you must show future financial responsibility (SR-22 insurance), and pay a reinstatement fee of $100 to $500, in addition to the fee for the license being requested, to have your driving privileges restored. A notice of suspension returned by the post office because of an incorrect address on your driver’s license or DMV records will not invalidate the suspension if the notice was mailed to the last address you provided to DMV.

IMPORTANT: THIS FORM MUST BE COMPLETED IN FULL AND MAILED OR FAXED TO THE DIVISION OF MOTOR VEHICLES WITHIN 15 DAYS FROM THE DATE OF THE CRASH. A participant’s crash report is required if the crash was not investigated by a peace officer and the total amount of damage exceeds $2,000, or there was personal injury.

Mail or Fax Completed Form To:	STATE OF ALASKA	Fax: (907) 465-5509
	DIVISION OF MOTOR VEHICLES
	ATTN: DRIVER LICENSING	Phone: (907) 465-4361
	PO BOX 110221
	JUNEAU AK 99811-0221
Form 466 (Rev. 03/2011)	Alaska.gov/dmv	E-mail: DOA.DMV.JDS@Alaska.gov