West Virginia Division of Motor Vehicles · West Virginia state form
DMV-617-SR Application for Self-Insurance
Use DMV-617-SR to apply for a Certificate of Self-Insurance from the Division of Motor Vehicles and provide the required vehicle and financial information.
- What this form is
- DMV-617-SR is an application for a Certificate of Self-Insurance issued by the Division of Motor Vehicles. The applicant affirms that at least 26 motor vehicles are registered in its name and must provide a vehicle list and an itemized financial statement. The form also asks the applicant to affirm that there are no unpaid motor vehicle crash judgments and that it has not filed for bankruptcy or is not under bankruptcy protection.
- Who needs it
- A firm or corporation seeking a Certificate of Self-Insurance from the Division of Motor Vehicles can use this application.
- Why it needs a notary
- The application includes a sworn or affirmed statement and a notary section. The signature must be notarized, which can be done online with a commissioned online notary.
- How to submit it
- Complete the application and attach the vehicle list and itemized Financial Statement. Submit it to the Self-Insurance Coordinator of the Division of Motor Vehicles.
Questions
Who uses the DMV-617-SR application?
A firm or corporation seeking a Certificate of Self-Insurance from the Division of Motor Vehicles can use this application.
What attachments does the application require?
The application calls for a list of the applicant’s registered motor vehicles and an attached itemized Financial Statement showing total assets and liabilities.
Does DMV-617-SR need to be notarized?
Yes. The applicant swears or affirms the statements, and the form includes a notary public section. You can notarize the signature online with a commissioned online notary.