Form 4715 - Motor Carrier'S Insurance Self-Certification
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STATE OF MISSOURI
FORM
DEPARTMENT OF REVENUE
4715
MOTOR VEHICLE BUREAU
MOTOR CARRIER’S INSURANCE SELF-CERTIFICATION
(REV. 4-2007)
VEHICLE OWNER’S NAME
STREET ADDRESS, R.R. OR PO BOX NUMBER
CITY, STATE, ZIP CODE
I certify that I have insured all of my vehicles according to the
requirements of the Division of Motor Carrier and Railroad Safety
pursuant to Section 390.126, RSMo., and that such insurance is
in full force and effect.
VEHICLE OWNER’S SIGNATURE
DATE
MO 860-2793 (4-2007)
STATE OF MISSOURI
FORM
DEPARTMENT OF REVENUE
4715
MOTOR VEHICLE BUREAU
MOTOR CARRIER’S INSURANCE SELF-CERTIFICATION
(REV. 4-2007)
VEHICLE OWNER’S NAME
STREET ADDRESS, R.R. OR PO BOX NUMBER
CITY, STATE, ZIP CODE
I certify that I have insured all of my vehicles according to the
requirements of the Division of Motor Carrier and Railroad Safety
pursuant to Section 390.126, RSMo., and that such insurance is
in full force and effect.
VEHICLE OWNER’S SIGNATURE
DATE
MO 860-2793 (4-2007)
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