Form 5042 Certification By Insurance Company Of Vehicle Damage

User Manual: 5042

Open the PDF directly: View PDF PDF.
Page Count: 1

DownloadForm 5042 - Certification By Insurance Company Of Vehicle Damage
Open PDF In BrowserView PDF
Reset Form
Form

5042

Print Form

Missouri Department of Revenue
Certification by Insurance Company
of Vehicle Damage

Street Address of Insured or Owner

Claim Number

City

State

Zip Code

This form is to be used by insurance companies or owners applying for an Original or Salvage Missouri Certificate of Title as
the result of a settlement of a claim for loss due to damage or theft.

r

Insurance company applying for an Original Missouri Certificate of Title

Applicant and Reason for Applying

Year

r

Vehicle Identification Number (VIN)

Make

Vehicle Identification Number (VIN)

Owner applying for a Salvage Missouri Certificate of Title
Year

r

Make

Owner applying for an Original Missouri Certificate of Title
Year

r

Vehicle Identification Number (VIN)

Insurance company applying for a Salvage Missouri Certificate of Title
Year

r

Make

Make

Vehicle Identification Number (VIN)

The insurance company is surrendering a salvage title to be redeemed for an original title due to recovery of a stolen
vehicle. A completed Vehicle Examination Certificate (Form 551) inspection must be submitted. The estimated cost to
repair the damage to the vehicle is 80 percent or less of the pre-damaged fair market value in accordance with
Section 301.010 (51) RSMo. The total cost of repairs does not include the cost of repairing, replacing, or reinstalling
inflatable safety restraints, tires, sound systems, or damage as a result of hail, or any sales tax on parts or materials. The
Form 551 inspection must be completed by the Missouri State Highway Patrol or the St. Louis City or County Authorization
Theft Unit.

Signature

I understand this certification will be used to apply for an Original or Salvage Certificate of Title in the insurance company or
owner name for this motor vehicle, trailer, or all-terrain vehicle and that any false statements in this certification will subject me
to civil and criminal liability.
I hereby certify under penalty of perjury that all information regarding this request is true and accurate and is made without
intent to defraud.
Signature of Authorized Agent or Owner
Printed Name

Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
Form 5042 (Revised 02-2014)

Mail to:

Motor Vehicle Bureau		
P.O. Box 2076
Phone: (573) 526-3669
Jefferson City, MO 65105-2076

Visit http://dor.mo.gov/motorv/
for additional information.
Source Exif Data: 
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.7
Linearized                      : Yes
Author                          : Missouri Department of Revenue
Create Date                     : 2017:07:26 11:11:13-05:00
Modify Date                     : 2017:07:26 11:23:31-05:00
Has XFA                         : No
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.4-c006 80.159825, 2016/09/16-03:31:08
Metadata Date                   : 2017:07:26 11:23:31-05:00
Creator Tool                    : Adobe InDesign CS6 (Windows)
Instance ID                     : uuid:9eb58e30-b22f-4897-8cd8-9b7cac12604d
Original Document ID            : xmp.did:75C30A947251E011A12DB2E6707ACDF0
Document ID                     : xmp.id:1708CA071D72E711A00AD28FCE0143B2
Rendition Class                 : proof:pdf
History Action                  : converted
History Parameters              : from application/x-indesign to application/pdf
History Software Agent          : Adobe InDesign CS6 (Windows)
History Changed                 : /
History When                    : 2017:07:26 11:11:13-05:00
Derived From Instance ID        : xmp.iid:1608CA071D72E711A00AD28FCE0143B2
Derived From Document ID        : xmp.did:75C30A947251E011A12DB2E6707ACDF0
Derived From Original Document ID: xmp.did:75C30A947251E011A12DB2E6707ACDF0
Derived From Rendition Class    : default
Format                          : application/pdf
Title                           : Form 5042 - Certification by Insurance Company of Vehicle Damage
Creator                         : Missouri Department of Revenue
Producer                        : Adobe PDF Library 10.0.1
Trapped                         : False
State                           : 1
Version                         : 1.1
Page Count                      : 1
Signing Date                    : 2017:07:26 11:23:30-05:00
Signing Authority               : ARE Acrobat Product v8.0 P23 0002337
Annotation Usage Rights         : Create, Delete, Modify, Copy, Import, Export
Document Usage Rights           : FullSave
Form Usage Rights               : Add, FillIn, Delete, SubmitStandalone
Signature Usage Rights          : Modify
EXIF Metadata provided by EXIF.tools

Navigation menu