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FR 44 (01/01/2008)

VIRGINIA

UNIFORM FINANCIAL RESPONSIBILITY

CERTIFICATE

Purpose:

Instructions:

Use this form to comply with Virginia Code §46.2-316 C for a motor vehicle liability insurance policy with coverage that is double the minimum limits generally required by Virginia Code §46.2-472. Send completed form to Insurance Verification Office at the above address.

INSURED PERSON INFORMATION

INSURED NAME (Last)

(first)

(middle)

(suffix)

STREET ADDRESS

CITY

STATE

ZIP CODE

DRIVER LICENSE NUMBER

ISSUING STATE

BIRTH DATE (mm/dd/yyyy)

INSURANCE COMPANY INFORMATION

INSURANCE COMPANY NAME

CASE NUMBER (optional)

NAIC CODE

POLICY NUMBER

CERTIFICATION EFFECTIVE DATE

This certification is effective on the above Certification Effective Date and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of Virginia. The insurance certified is provided by an:

VEHICLE YEAR

VEHICLE MAKE

VEHICLE IDENTIFICATION NUMBER (VIN)

VEHICLE YEAR

VEHICLE MAKE

VEHICLE IDENTIFICATION NUMBER (VIN)

VEHICLE YEAR

VEHICLE MAKE

VEHICLE IDENTIFICATION NUMBER (VIN)

VEHICLE YEAR

VEHICLE MAKE

VEHICLE IDENTIFICATION NUMBER (VIN)

OWNER'S POLICY - Applicable to the following described vehicle(s) and subject to the terms and conditions defined in the owner's insurance policy.

OPERATOR'S POLICY - Applicable to any vehicle not registered/titled to the above listed person and subject to the terms and conditions defined in the operator's insurance policy.

The company signatory certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws of Virginia, which policy becomes effective on the above Certification Effective Date.

AUTHORIZED REPRESENTATIVE SIGNATURE

DATE

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