Installment Contract Form - Nebraska
INSTALLMENT AGREEMENT FORM
(ACCIDENT / DEFAULT IN PAYMENT SUSPENSIONS ONLY)
SUSPENDED DRIVER’S PERSONAL INFORMATION (Please Print):
Last Name First Name Middle Initial Suffix (Jr., Sr., 2
nd
, 3
rd
)
Current Mailing Address Required (Street or PO Box) City State Zip Code
DATE OF BIRTH DRIVER’S LICENSE NUMBER SOCI AL SECURITY NUMBER (OPTIONAL)
Month Day Year
DATE OF LOSS / ACCIDEN T LOC ATION OF LOSS / ACCIDENT
Month Day Year
TERMS OF THE AGREEMENT:
Agreement covers the following (check [√] applicable below):
(√)
Property damages for:
Name Address
(√)
Personal injury for:
Name Address
**Medical payments pending (if applicable) for:
Name
Total dollar amount due or financed:
$
Frequency of payments (√ applicable):
Weekly:
(√)
Monthly:
(√)
Yearly:
(√)
Dollar amount of each payment: $
Date of first payment:
Month Day Year
SIGNATURES BELOW MUST BE EITHER WITNESSED OR NOTARIZED:
Suspended Driver’s Signature: Other Party (individual, insurance company, attorney, etc.) Signature:
Title of Position (for insurance company, attorney, etc.): Mailing Address:
Signing on behalf of (for insurance company, attorney, subrogee of , etc.):
Witness Signature (Must be a non-interested party):
Date:
Witness Signature (Must be a non-interested party):
Date:
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this
______ day of _________________, 20_____ by:
________________________________________
Name of suspended driver
Notary:
State of ________________________
County of ______________________
The foregoing instrument was acknowledged before me this
_______ day of __________________, 20_____ by:
__________________________________________
Name of other party or representative
↑Affix seal here↑
______________________________
Notary Public Signature ↑Affix seal here↑
________________________________
Notary Public Signature
**If medical payments are pending at time Installment Agreement is signed, you will be required to provide an
updated Installment Agreement form once the dollar amount is agreed upon.
Note: Installment Agreement is VOID unless all signatures are either witnessed or notarized.
Neb. Rev. Stat. 60-510(4)
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