SI-02 (Revised 9/2018) Page 2 of 2
Central Services Division
Vehicle Programs
555 Wright Way
Carson City, Nevada 89711
(775) 684-4491
Email: DMVSelfInsurance@dmv.nv.gov
You must answer ALL questions.
Yes
No
Have you previously held a Certificate of Self-Insurance either with DMV or another agency?
Explain.
Yes
No
Have you had a Self-Insurance Certificate cancelled within the last year either with DMV or another
agency? Explain.
Yes
No
Have you provided to the Department security in the amount established in NAC 485.080?
Yes
No
Have you included with this application the CPA Affidavit of Audit and Current Financial Ratio?
Note: The Department’s minimum requirement for current financial ratio is 91%.
Yes
No
For entities making a joint application, have you included the indemnity agreement (original or notarized
copy)? If you are not making a joint application, please write in “N/A” under “No.”
Yes
No
Have you provided the required motor vehicle information for your business?
Vehicle Identification Number Make of Vehicle
Nevada License Plate Number Model of Vehicle
Yes
No
Have you included a Self-Insurance Loss Experience Record form?
Yes
No
Are there any open and unsatisfied judgments against your business? Explain.
Yes
No
Is this a taxicab company?
NOTE: THIS APPLICATION FOR SELF-INSURANCE IS TO BE SIGNED ONLY
BY INDIVIDUAL, SOLE PROPRIETOR, PARTNER, OR OFFICER OF THE CORPORATION.
I am performing an insurance function and I expressly agree, as a condition to the granting of a Certificate of Self-
Insurance, to abide by and follow the provisions of NRS 485.380 and NAC 485.010 to 485.120 inclusive and
NRS 686A.310 and NAC 686A.600 to 686A.680, concerning unfair practices in settling claims and any regulations
adopted by the Commission of Insurance.
I also consent to the jurisdiction of the Commission of Insurance to interpret the aforementioned Statutes and
Regulations in any informal administrative or court proceeding.
The
undersigned, herein referred to as the applicant, being the owner of more than ten motor vehicles actively
registered in the State of Nevada, hereby makes application for a Certificate of Self-Insurance. In so doing, I hereby
certify that all statements in this application are true and correct. I agree and understand any misstatements of
material facts are cause for cancellation and/or denial of the Certificate of Self-Insurance.
Printed Name Title
Signature Date
NOTARIZATION:
State of , County of
I certify that on the date set forth below, the individual named above did appear
personally before me and that I did identify this individual. The statements on
this document are subscribed and sworn to before me by the endorsee on this
day of , .
Notary Public Signature:
My Commission Expires:
