PS Form 2480 - branch 38
PS Form 2480 - branch 38
PS Form 2480 - branch 38
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9. Describe Any Motor Vehicle Accidents You Have Had Within the Last 5 Years in Which You Were the Driver in the Spaces Below. Use an Extra Sheet to<br />
Describe Any Accident(s) You Have Had Within the Last 5 Years in Excess of 3.<br />
Accident No. 1<br />
Place (City or Town, State)<br />
Date of Accident<br />
Describe How the Accident Happened<br />
Amount of Damage to Your Vehicle Amount of Damage to Other Party's<br />
Vehicle<br />
$ _____________________ $ _____________________<br />
Was Anyone Killed<br />
5 Yes 5 No<br />
Give the Name of the Court or Other Legal Body That Made the Judgment<br />
Did You or Your Insurance Company Make Payment to Other Party<br />
Were You Judged at Fault<br />
5 Yes 5 No<br />
Accident No. 2<br />
Place (City or Town, State)<br />
Date of Accident<br />
Describe How the Accident Happened<br />
Amount of Damage to Your Vehicle Amount of Damage to Other Party's<br />
Vehicle<br />
$ _____________________ $ _____________________<br />
Was Anyone Killed<br />
5 Yes<br />
5 No<br />
Give the Name of the Court or Other Legal Body That Made the Judgment<br />
Did You or Your Insurance Company Make Payment to Other Party<br />
Were You Judged at Fault<br />
5 Yes 5 No<br />
Accident No. 3<br />
Place (City or Town, State)<br />
Date of Accident<br />
Describe How the Accident Happened<br />
Amount of Damage to Your Vehicle Amount of Damage to Other Party's Did You or Your Insurance Company Make Payment to the Other Party<br />
Vehicle<br />
$ _____________________ $ _____________________<br />
Was Anyone Killed<br />
Were You Judged at Fault<br />
5 Yes 5 No 5 Yes 5 No<br />
Give the Name of the Court or Other Legal Body That Made the Judgment<br />
I Certify That All of the Statements Made in This Application are True, Complete, and Correct to the Best of My Knowledge and Belief, and Are Made in<br />
Good Faith.<br />
Signature of Applicant<br />
Date<br />
<strong>PS</strong> <strong>Form</strong> <strong>2480</strong>, April 1992 (Reverse)
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