![]() TENNESSEE DEPARTMENT OF SAFETY AND HOMELAND SECURITYĪs set forth under the provisions of 55-12-104, T.C.A., you must file, or have filed in your behalf, a personal report with the Department of Safety, if you were involved in an automobile crash as an owner or driver involving death or injury, or in which damage to property was in excess of four hundred dollars ($400) to any person involved. NOTE: THE INSURANCE INFORMATION YOU PROVIDE WILL BE FORWARDED TO THE INSURANCE COMPANY FOR VERIFICATION. NAME OF INSURANCE REPRESENTATIVE (AGENCY) WHO ISSUED POLICY _ ![]() ![]() POLICY NUMBER _ POLICY PERIOD: FROM _ TO _ IF YES, PROVIDE COMPLETE INFORMATION BELOW: (Last Name) (First Name) (Middle Initial) (Driver License Number)ĭID YOU HAVE LIABILITY INSURANCE COVERAGE FOR THIS CRASH? YES_ NO _ IF AVAILABLE, LIST FOLLOWING INFORMATION ON OTHER DRIVER INVOLVED IN THIS CRASH: WERE THERE INJURIES OR DEATH INVOLVED IN THIS CRASH? _ YES _NOĭAMAGES TO YOUR VEHICLE: _ LESS THAN $400 _ OVER $400. NAME OF OPERATOR _ DOB _ĪDDRESS _ ZIP _ĭRIVER LICENSE NO: _ STATE _ EXPIRATION DATE _ VEHICLE MAKE _ VEHICLE YEAR _ TYPE VEHICLE _ IMPORTANT: COMPLETE FORM BELOW AND MAIL TO: TN DEPARTMENT OF SAFETY AND HOMELAND SECURITY P.O. Landlord (Tenant) Recommendation Letter.
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