SR-22 FINANCIAL RESPONSIBILITY FORM
[Pages:1]SR-22
FINANCIAL RESPONSIBILITY FORM
Name
{ Insured
Last
First
Address
Case Number
Driver's License Number
Birth Date
Middle
Social Security Number
Current Policy Number _________________________Effective From _______________________________ This certification is effective from __________________________________ and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of this State. The insurance hereby certified is provided by an:
OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the date of acquisition.
Model Year
Trade Name
Identification Number
OPERATOR'S POLICY: Applicable to any non-owned vehicle.
TEXAS FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE The company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws to this State, which policy is in effect on the effective date of this certificate.
Name of Insurance Company
MGA Insurance Company, Inc.
Date ________________ By_____________________________________________________________
Signature of Authorized Representative
SR-22
FINANCIAL RESPONSIBILITY FORM
Name
{ Insured
Last
First
Address
Case Number
Driver's License Number
Birth Date
Middle
Social Security Number
Current Policy Number _________________________Effective From _______________________________ This certification is effective from __________________________________ and continues until cancelled or terminated in accordance with the financial responsibility laws and regulations of this State. The insurance hereby certified is provided by an:
OWNER'S POLICY: Applicable to (a) the following described vehicle(s), (b) any replacement(s) thereof by similar classification, and (c) any additionally acquired vehicles of similar classification for a period of at least 30 days from the date of acquisition.
Model Year
Trade Name
Identification Number
OPERATOR'S POLICY: Applicable to any non-owned vehicle.
TEXAS FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE The company signatory hereto hereby certifies that it has issued to the above named insured a motor vehicle liability policy as required by the financial responsibility laws to this State, which policy is in effect on the effective date of this certificate.
Name of Insurance Company
MGA Insurance Company, Inc.
Date ________________ By_____________________________________________________________
Signature of Authorized Representative
Enclosed Please Find SR-22 Forms. Should You Have Any Questions Please Contact
Our Customer Service Department at 1(800) 699-1561
Thank You.
GAINSCO Auto Insurance
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