Alaska Department of Administration, Divison of Motor Vehicles
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CERTIFICATE OF INSURANCE
Failure to submit this form could result in the suspension of your driver's license.
Instructions: If you do not know a requested detail, please enter "Unknown".

CRASH INFORMATION
Date of Crash  
 Incident/Case #

Location of Crash (City)
DRIVER INFORMATION
First Name  
Middle Name
 Last Name  
Date of Birth    
Driver's License #  
Driver's License State  
Contact Phone 
 E-mail Address
Mailing Address  
City  
State  
Zip Code 
 Country
OWNER OF VEHICLE INFORMATION
              
First Name  
Middle Name
 Last Name  
Date of Birth  
Driver's License #   
Driver's License State   
Contact Phone  
E-mail Address
Mailing Address
City
State
Zip Code  
 Country
VEHICLE INFORMATION
Year  
Make  
Model
License Plate  
VIN   
INSURANCE INFORMATION
Did you have or were you covered by an automobile liability policy in effect covering this crash?    
Policy Holder Name  
Insurance Company  
Policy Number  
Policy Period Covering the Date of Crash
   To       
Insurance Agent Name
Insurance Agent Address
Insurance Agent Phone Number
Insurance Agent E-mail Address
 
Click 'Next' to review your information