Uninsured Motorist Complaint Form {ICD-034}

Uninsured Motorist Complaint Form Uninsured Motorist Complaint Form Alleged Uninsured Motorist's Information Vehicle Owner's Name- First Middle Last Motor Vehicle Administration Glen Burnie, Maryland 21062 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 Motor Vehicle Administration 6601 Ritchie Highway, N.E. ICD-034 (09-03) ICD-034_03-13 Street Address Vehicle Tag Number Insurance Company Vehicle Year City Make Policy Number State Vehicle Operator Zip Code Nature of Complaint 1. Accident Date Location Amount of Damages to your Property Personal Injuries Sustained? Yes No Police Report Number (Attach Copy) Officer's Name 2. Other (Specify date, location, and description of incident. Use other side if necessary) Company contacted regarding alleged uninsured motorist's insurance information and results of contact. (Attach supporting correspondence from company contacted) Explain results of contact with alleged uninsured motorist Complainant Name (print)- First Street Address Signature City Middle State Last Zip Code Client Name (print) - First Middle Last Home Telephone Number Claim Number: Work Telephone Number Date Check here if notice of results is needed. The Motor Vehicle Administration cannot assist in collection for damages sustained in a motor vehicle accident. If the vehicle in question is uninsured, suspension action may be taken against the owner's driving and registration privileges in accordance with Maryland's compulsory insurance laws. Mail completed form and, if available, copies of police reports and letters you received from insurance companies disclaiming coverage to: Motor Vehicle Administration, Insurance Compliance Division, 6601 Ritchie Highway N.E., Glen Burnie 21062; telephone (410) 768-7291, fax (410) 787-2953. For more information, please call: 410-768-7000 (to speak with a customer service representative). TTY 1-800-638-8347 (touch 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov For more information, please call:for the hearing impaired:tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative), American LegalNet, From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.marylandmva.com Inc. www.FormsWorkFlow.com