Form Dpsmv 3011 PDF Details

The Dpsmv 3011 form serves as a critical tool for individuals in Louisiana seeking to navigate the aftermath of a motor vehicle accident. This document is designed to facilitate the process of claiming recovery for property damages and/or injuries that occur as a result of such incidents. Managed by the Office of Motor Vehicles and in accordance with R.S. 32:871, it provides a structured means for insured motorists, property owners, or injured parties to formally submit their claims. The form requires detailed information regarding the accident, including the date, location, and parties involved, both the claimant and the alleged responsible party. It also asks for specifics about the vehicle(s) involved, insurance coverage at the time of the accident, the extent of vehicle and property damage, and a thorough account of injuries or deaths that resulted. This form underscores the importance of proving liability insurance or other security was in effect at the time of the accident to proceed with a claim. By completing and submitting this form, individuals assert their belief in their entitlement to recover damages or medical expenses due to the incident, a process underscored by the requirement to certify the truthfulness of the information provided. This guide intends to demystify the process, offering clarity and support to those navigating the potentially complex waters of post-accident claims in Louisiana.

QuestionAnswer
Form NameForm Dpsmv 3011
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSUBMITTING, Louisiana, resulting, expresslane

Form Preview Example

OFFICE OF MOTOR VEHICLES

P.O. BOX 64886, BATON ROUGE, LA 70896-4886

1-225-925-6146 www.expresslane.org

SAFETY RESPONSIBILITY CLAIM FORM

In accordance with the provisions of R.S. 32:871, an insured motorist, property owner or injured person may make a claim for the recovery of property damages and /or injuries resulting from a motor vehicle accident that occurred in Louisiana. If your vehicle was involved in this accident, you must provide proof that your vehicle was covered by liability insurance or other security at the time of the accident.

DATE AND LOCATION OF ACCIDENT

DATE OF ACCIDENT (MM/DD/YY)

LOCATION OF ACCIDENT

CITY

PARISH

PERSON SUBMITTING CLAIM (Your Vehicle)

DRIVER'S NAME (FIRST, MIDDLE, LAST)

 

DRIVER'S LICENSE NUMBER

 

STATE

DATE OF BIRTH (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER'S ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP

SEX

 

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWNER OF VEHICLE

 

 

DRIVER'S LICENSE NUMBER

 

STATE

DATE OF BIRTH (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

OWNER'S ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP

SEX

 

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE (YEAR AND MAKE)

VEHICLE IDENTIFICATION NUMBER (VIN)

 

STATE

LICENSE PLATE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

LIABILITY INSURANCE INFORMATION AT TIME OF ACCIDENT OR ATTACH INSURANCE CARD/OTHER SECURITY

NAME OF INSURANCE COMPANY (NOT AGENCY OR BROKERAGE)

POLICY NUMBER

POLICY PERIOD (MM/DD/YY TO MM/DD/YY)

TO

PERSON(S) CLAIM IS AGAINST (Other Vehicle)

DRIVER'S NAME (FIRST, MIDDLE, LAST)

 

DRIVER'S LICENSE NUMBER

 

STATE

DATE OF BIRTH (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER'S ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP

SEX

 

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWNER OF VEHICLE

 

 

DRIVER'S LICENSE NUMBER

 

STATE

DATE OF BIRTH (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

OWNER'S ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP

SEX

 

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE (YEAR AND MAKE)

VEHICLE IDENTIFICATION NUMBER (VIN)

 

STATE

LICENSE PLATE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

DAMAGE TO VEHICLE

DAMAGE TO OTHER PROPERTY (Telephone poles, fences, etc.)

 

 

 

 

 

 

 

 

 

AMOUNT

 

DESCRIPTION

 

 

 

 

AMOUNT

 

 

 

 

 

 

 

INJURIES AND/OR DEATHS CAUSED BY THE ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

ADDRESS

CITY

STATE

ZIP

MEDICAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

UNDER AGE 18

 

 

 

 

 

 

 

 

 

NAME

ADDRESS

CITY

STATE

ZIP

MEDICAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

UNDER AGE 18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

ADDRESS

CITY

STATE

ZIP

MEDICAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

UNDER AGE 18

 

 

 

 

 

 

 

 

 

NAME

ADDRESS

CITY

STATE

ZIP

MEDICAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

UNDER AGE 18

 

 

 

 

 

 

 

 

 

As a result of this motor vehicle accident, I believe I am entitled to recovery of the indicated property damages and/or medical expenses from the person(s) this claim is against, and that I have not released said person(s). I certify by signing below that the information entered by me on this document is true and correct to the best of my knowledge.

DATE (MM/DD/YY)

PRINT NAME

X

SIGN NAME

X

DPSMV 3011 (R 06/13)

How to Edit Form Dpsmv 3011 Online for Free

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If you want to fill out this PDF form, make sure that you enter the right details in every blank:

1. Fill out the SUBMITTING with a number of necessary fields. Consider all of the information you need and make sure nothing is omitted!

Tips on how to fill in certify portion 1

2. Your next step is usually to complete these blank fields: OWNER OF VEHICLE, DRIVERS LICENSE NUMBER, STATE, DATE OF BIRTH MMDDYY, OWNERS ADDRESS NUMBER AND STREET, SEX MALE FEMALE, VEHICLE YEAR AND MAKE, VEHICLE IDENTIFICATION NUMBER VIN, STATE, LICENSE PLATE NUMBER, DAMAGE TO VEHICLE, DAMAGE TO OTHER PROPERTY Telephone, AMOUNT, DESCRIPTION AMOUNT, and INJURIES ANDOR DEATHS CAUSED BY.

DAMAGE TO VEHICLE, VEHICLE YEAR AND MAKE, and INJURIES ANDOR DEATHS CAUSED BY in certify

It is easy to get it wrong when filling in the DAMAGE TO VEHICLE, and so be sure you reread it before you'll submit it.

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