
If this vehicle is driven by the person(s) named below, residual liability insurance does not
apply and the vehicle will be considered uninsured:
WARNING - when a named excluded person operates a vehicle, all liability coverage is void -
no one is insured. Owners of the vehicle and others legally responsible for the acts of the
named excluded person remain fully responsible.
Michigan Law (MCLA 500.3101) requires that the owner or registrant of a motor vehicle regis-
tered in this state must have insurance or other approved security for the payment of no-fault
benefits on the vehicle at all times. An owner or registrant who drives or permits a vehicle to
be driven upon a public highway without the proper insurance or other security is guilty of a
misdemeanor.
An owner or registrant convicted of such a misdemeanor shall be fined not less than $200.00
nor more than $500.00, or imprisoned for not more than 1 year, or both.
A PERSON WHO SUPPLIES FALSE INFORMATION TO THE SECRETARY OF STATE OR WHO
ISSUES OR USES AN INVALID CERTIFICATE OF INSURANCE IS GUILTY OF A MISDEMEAN-
OR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN 1 YEAR, OR A FINE OF NOT
MORE THAN $1,000.00, OR BOTH.
ACORD 50 MI (2007/12) © 1993, 2007 ACORD CORPORATION. All rights reserved.
If this vehicle is driven by the person(s) named below, residual liability insurance does not
apply and the vehicle will be considered uninsured:
WARNING - when a named excluded person operates a vehicle, all liability coverage is void -
no one is insured. Owners of the vehicle and others legally responsible for the acts of the
named excluded person remain fully responsible.
Michigan Law (MCLA 500.3101) requires that the owner or registrant of a motor vehicle regis-
tered in this state must have insurance or other approved security for the payment of no-fault
benefits on the vehicle at all times. An owner or registrant who drives or permits a vehicle to
be driven upon a public highway without the proper insurance or other security is guilty of a
misdemeanor.
An owner or registrant convicted of such a misdemeanor shall be fined not less than $200.00
nor more than $500.00, or imprisoned for not more than 1 year, or both.
A PERSON WHO SUPPLIES FALSE INFORMATION TO THE SECRETARY OF STATE OR WHO
ISSUES OR USES AN INVALID CERTIFICATE OF INSURANCE IS GUILTY OF A MISDEMEAN-
OR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN 1 YEAR, OR A FINE OF NOT
MORE THAN $1,000.00, OR BOTH.
ACORD 50 MI (2007/12) © 1993, 2007 ACORD CORPORATION. All rights reserved.
Michigan Law (MCLA 500.3101) requires that the owner or registrant of a motor vehicle regis-
tered in this state must have insurance or other approved security for the payment of no-fault
benefits on the vehicle at all times. An owner or registrant who drives or permits a vehicle to
be driven upon a public highway without the proper insurance or other security is guilty of a
misdemeanor.
An owner or registrant convicted of such a misdemeanor shall be fined not less than $200.00
nor more than $500.00, or imprisoned for not more than 1 year, or both.
THIS FORM MUST BE PRESENTED AS EVIDENCE OF INSURANCE WITH YOUR APPLICA-
TION FOR LICENSE PLATES, EITHER BY MAIL OR AT ANY SECRETARY OF STATE LICENSE
PLATE BRANCH OFFICE. A PERSON WHO ISSUES OR WHO SUPPLIES FALSE INFORMA-
TION TO THE SECRETARY OF STATE OR USES AN INVALID CERTIFICATE OF INSURANCE
IS GUILTY OF A MISDEMEANOR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN
1 YEAR, OR A FINE OF NOT MORE THAN $1,000.00, OR BOTH.
If this vehicle is driven by the person(s) named below, residual liability insurance does not
apply and the vehicle will be considered uninsured:
WARNING - when a named excluded person operates a vehicle, all liability coverage is void -
no one is insured. Owners of the vehicle and others legally responsible for the acts of the
named excluded person remain fully responsible.
ACORD 50 MI (2007/12) © 1993, 2007 ACORD CORPORATION. All rights reserved.
Michigan Law (MCLA 500.3101) requires that the owner or registrant of a motor vehicle regis-
tered in this state must have insurance or other approved security for the payment of no-fault
benefits on the vehicle at all times. An owner or registrant who drives or permits a vehicle to
be driven upon a public highway without the proper insurance or other security is guilty of a
misdemeanor.
An owner or registrant convicted of such a misdemeanor shall be fined not less than $200.00
nor more than $500.00, or imprisoned for not more than 1 year, or both.
THIS FORM MUST BE PRESENTED AS EVIDENCE OF INSURANCE WITH YOUR APPLICA-
TION FOR LICENSE PLATES, EITHER BY MAIL OR AT ANY SECRETARY OF STATE LICENSE
PLATE BRANCH OFFICE. A PERSON WHO ISSUES OR WHO SUPPLIES FALSE INFORMA-
TION TO THE SECRETARY OF STATE OR USES AN INVALID CERTIFICATE OF INSURANCE
IS GUILTY OF A MISDEMEANOR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN
1 YEAR, OR A FINE OF NOT MORE THAN $1,000.00, OR BOTH.
If this vehicle is driven by the person(s) named below, residual liability insurance does not
apply and the vehicle will be considered uninsured:
WARNING - when a named excluded person operates a vehicle, all liability coverage is void -
no one is insured. Owners of the vehicle and others legally responsible for the acts of the
named excluded person remain fully responsible.
ACORD 50 MI (2007/12) © 1993, 2007 ACORD CORPORATION. All rights reserved.
VEHICLE COPY - REVERSE SIDESECRETARY OF STATE'S COPY - REVERSE SIDE