PROOF OF INSURANCE FORM

TAKE THIS FORM TO YOUR INSURANCE AGENT BEFORE YOU APPEAR IN COURT.

AT THE TIME OF OFFENSE (DATE): _________________

WAS THE DRIVER/VEHICLE OWNER COVERED BY PROPERTY DAMAGE AND BODILY INJURY LIABILITY AS REQUIRED BY THE OHIO REVISED CODE SECTION 4509.101:

_______YES     _______NO

NAME AND ADDRESS OF INSURANCE COMPANY:

_______________________________________________

_______________________________________________

_______________________________________________

DRIVER NAME: _____________________________________________

ADDRESS: _________________________________________________

NAME IN  WHICH POLICY WAS ISSUED: ____________________________________

INSURANCE POLICY NUMBER: _________________________________

EFFECTIVE DATES FROM: ______________ TO ______________

SOCIAL SECURITY NUMBER: _____________________________

DATE OF BIRTH: _____________       LICENSE PLATE NO: ____________________

YEAR OF VEHICLE: __________      MAKE OF VEHICLE: _______________________

SERIAL NUMBER OF VEHICLE: ____________________________________

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SIGNATURE OF INSURANCE AGENT OR AUTHORIZED INSURANCE COMPANY REPRESENTATIVE AND ADDRESS