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:______________________________________

OWNER 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:____________________________

____________________________________________________
SIGNATURE OF INSURANCE AGENT OR AUTHORIZED INSURANCE COMPANY REPRESENTATIVE AND ADDRESS