Fillable LESSOR LIABILITY POLICY OF INSURANCE CERTIFICATION (Wisconsin)

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LESSOR LIABILITY POLICY OF INSURANCE CERTIFICATION (Wisconsin)

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LESSOR LIABILITY POLICY OF INSURANCE CERTIFICATION
Wisconsin Department of Transportation
MV2519 10/2020
Policy Number
Beginning Date (mm/dd/yyyy)
End date (mm/dd/yyy) or Continuous
Policy Face Amount
Legal Business Name – (No DBA Information)
Legal Business Address – Street
City
Zip Code
Insurance Company Name
Insurance Location (City, State)
The above-named dealer as principal and the above-named corporation duty licensed and authorized to transact business in the State
of Wisconsin as insurance are firmly bound to the State of Wisconsin as liable for damages caused by the negligent operation of a
motor vehicle leased from the lessor. The face amount of the policy is the sum stated above, lawful money of the United States of
America, as made and provided for under Chapter 344 Wisconsin Statutes.
This policy is given to satisfy the provisions and conditions of Wis. Stat. §344.51(1m).
Within 10 days of any claim made against this policy said insurance company shall mail notice to the Wisconsin
Department of Transportation.
The policy and all obligations under it shall remain continuously in full force and effect through the date shown above. Any changes to
the policy information reflected in this document will require submission of a new MV2519.
If the policy is terminated and not immediately replaced with another comparable policy, the principal shall be directly liable for
damages caused by the negligence of any person operating the leased vehicle in any period for which coverage has lapsed and said
principal may be subject to a monetary forfeiture of not more than $200 or administrative action per Wis. Stat. §218.0116(1)(gm).
(Print – Legal Business Name – No DBA Information)
(Print – Insurance Company Name)
X
X
(Signature – Owner) (Date Signed mm/dd/yyyy)
(Signature of Insurance Officer, Attorney-in-Fact) (Date Signed mm/dd/yyyy)
Mail or Email to:
Wisconsin Division of Motor Vehicles
Dealer and Agent Section
ATTN: Apps Department
4822 Madison Yards Way
Madison, WI 53705
EMVPARTNER@dot.wi.gov
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LESSOR LIABILITY POLICY OF INSURANCE CERTIFICATION (Wisconsin)

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Completed 9 February 2021

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