Line 16: Enter the year for the mileage reporting period for which the miles are being reported.
Schedule BN must be signed by the responsible person. Please include the person's job title and the date.
Print or type the full name of your insurance company (not the agency or the group). Enter your policy number and all the additional information requested.
Indiana law requires every motor vehicle registered in the State of Indiana to have proof of financial responsibility.
Proof of financial responsibility includes one of the following:
1. Motor vehicle's insurance policy
2. Self insurance (certificate from BMV required)
3. Indiana Motor Carrier Authority Number (IMCA) (PSCI)
4. $40,000 in securities or cash deposited with the Treasurer of Indiana
NOTE: If qualified under 2 or 3, place your IMCA number or certificate of self insurance number in the policy number area on the front of this form.
If qualified under 4, place the word "BOND" in the insurance company name area on the front of this form.
Falsification of this information will subject you to a jail term of up to two years, a fine of up to $10,000, and suspension of your driver's license for a period of up to one year.