Form 5042 Certification By Insurance Company Of Vehicle Damage
User Manual: 5042
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Form
5042
Missouri Department of Revenue
Certification by Insurance Company
of Vehicle Damage
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.
Form 5042 (Revised 02-2014)
r Insurance company applying for an Original Missouri Certificate of Title
Year Make Vehicle Identification Number (VIN)
r Insurance company applying for a Salvage Missouri Certificate of Title
Year Make Vehicle Identification Number (VIN)
r Owner applying for an Original Missouri Certificate of Title
Year Make Vehicle Identification Number (VIN)
r Owner applying for a Salvage Missouri Certificate of Title
Year Make Vehicle Identification Number (VIN)
r 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.
Applicant and Reason for Applying
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.
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)
__ __ / __ __ / __ __ __ __
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