Indiana SR21 Form – Fill Out and Use This PDF

The Indiana SR21 form, officially known as the Indiana Operator’s Proof of Insurance/Crash Report, is a document for drivers involved in vehicle collisions within the state. This form verifies insurance coverage at the time of the accident. It must be submitted to the Bureau of Motor Vehicles, particularly for accidents resulting in injury, death, or property damage of $1000 or more.

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Indiana SR21 Form PDF Details

The SR21 form is officially titled "Indiana Operator’s Proof of Insurance/Crash Report." As its designation implies, this form is used to verify insurance during a collision and, secondly, as a detailed account of the crash. Required in situations where a collision results in injury, death, or property damage surpassing $1000, the form must be filled and submitted within a ten-day window post-incident.

The document captures the accident's time, location, and specifics, alongside the involved parties' personal information and the reporting party's insurance details. Notably, the form includes a section that must bear the signature of the insurance agent, validating the existence of an insurance policy at the accident's moment. Failure to report, as mandated, or the absence of an insurance agent's signature, implicates the driver was uninsured at the crash time, leading to the suspension or revocation of driving privileges and car registration.

This form is used for administrative purposes under the Safety Responsibility Law and to collect data to prevent future accidents. Therefore, it's essential for drivers in Indiana to fully understand how to complete the SR21 form properly and comply with its requirements.

Question	Answer
Form Name	Indiana SR21 Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	63
Avg. time to fill out	10 min
Other names	SR 21 form, Indiana proof form, SR21 Indiana, SR 21 Indiana

Form Preview Example

INDIANA OPERATOR’S PROOF OF INSURANCE/CRASH REPORT

STATE FORM 52441 (R / 2-06) / SR21

Collision Date

Day of Week

Actual Local Time

# of Vehicles

Reporting Officer Name

Badge #

Send form to Bureau

MONTH

DAY

YEAR

of Motor Vehicles.

Do not send to

County where crash occurred

Nearest City/Town

Was Officer Report

Reporting Police Agency Name

Indiana State Police.

Taken?

Road Collision Occurred On:

Nearest Intersecting Road:

Direction and distance to nearest intersection:

Local ID

Insured

Print Driver’s Name (Last, First, MI)

Driver’s License Number

Address (Number, Street)

City

State

ZIP

Sex

DATE OF BIRTH

License Type

License State

Month

Day

Year

Print Owner’s Name & Address

Veh. Yr.

Make

Model

Lic. Yr.

Lic. Plate #

Lic. State

Other Drivers Involved

Print Driver’s Name (Last, First, MI)

Driver’s License Number	Sex		DATE OF BIRTH
		Month	Day	Year

Print Driver’s Name (Last, First, MI)

Driver’s License Number	Sex		DATE OF BIRTH
		Month	Day	Year

Print Driver’s Name (Last, First, MI)

Driver’s License Number	Sex		DATE OF BIRTH
		Month	Day	Year

Name of Person Submitting This Report

Date Signed

Signature

THIS SECTION MUST CONTAIN THE SIGNATURE OF YOUR INSURANCE AGENT, IF YOU HAD INSURANCE AT THE TIME OF THE COLLISION. The company signatory hereto gives notice that its policy issued to the above named insured is a motor vehicle liability policy approved by the Commissioner of Insurance of the State of Indiana and was in effect on the date of the above described collision. A signature by an insurance agent or authorized representative is verification that the above driver (Insured) was insured at the time of the collision. Omission of agent signature signifies the driver was NOT insured at the time of the collision.

Insurance Company

Agency Name

Phone #

Date of Certification

Insured’s Policy Number

Signature of Authorized Insurance Representative

Date

Instructions for Completing the Indiana Operator’s Crash Report

Collisions resulting in injury, death or damage of $1000 or more (as determined by the reporting officer) must be reported on this form within 10 days. PRINT ALL INFORMATION USING ALL CAPITAL LETTERS (except your signature). Complete in black or blue INK.

Answer all questions to the best of your knowledge. If you are unable to answer any question, mark “unknown” or “U”. If the answer does not apply, mark with a slash (\) through the box.

YOU ARE THE INSURED. LIST THE DRIVER INFORMATION FOR ALL OTHER DRIVERS INVOLVED IN THE COLLISION UNDER “OTHER DRIVERS INVOLVED”.

If you were insured at the time of the collision, you must have the signature of the insurance agent before mailing the report.

Please submit this report to:

Bureau of Motor Vehicles

Important! PFR/Crash Report Section

Send to: P.O. Box 7169

Indianapolis, IN 46207

BY LAW, YOUR REPORT IS CONFIDENTIAL AND CANNOT BE USED AS EVIDENCE IN ANY TRIAL IC 9-26-3-4

The driver of any motor vehicle involved in a crash that results in injury or death or total property damage of $1000 or more must make a report on this form within ten

(10)days. The failure or refusal of any person to report a crash as required is cause for the suspension or revocation of the operator’s or chauffeur’s license and vehicle registration of such person. Such failure or refusal is also a misdemeanor. If the driver is physically incapable of making the report, any occupant of the vehicle is required to do so. A witness may also be required to make a report. A supplementary report will be required whenever an original report is insufficient.

The purpose of this report is to obtain information necessary to the administration of the Safety Responsibility Law and to obtain data useful in crash prevention. Complete and clear answers to all the questions are necessary. An accurate original report will avoid the necessity for supplementary reports. If you have difficulty in filling in the report, consult your nearest police authority or Bureau of Motor Vehicles at (317) 232-2840.

How to Edit Indiana SR21 Form Online for Free

In a motor vehicle accident in Indiana that results in injury, death, or property damage totaling $1,000 or more, it is mandatory to complete and submit the Indiana Operator’s Proof of Insurance/Crash Report, commonly referred to as the SR21 form.

1. Write the Date and Time of the Collision

Start by writing the exact date (month, day, year) and the actual local time when the collision occurred. Specify whether it happened in the AM or PM.

2. Add Location and Officer Details

Record the county where the crash occurred, the nearest city or town, and whether an officer's report was taken at the scene. Include the reporting officer’s name and badge number.

3. Describe the Collision Scene

Detail the road where the collision occurred, the nearest intersecting road, and the direction and distance to the nearest intersection. You will also need to enter the local ID if available.

4. List All Drivers Involved

For yourself and each driver involved in the accident, provide full names, dates of birth, driver’s license numbers, addresses, and vehicle information, including year, make, model, and license plate numbers.

5. Insurance Verification

This is a section where you must have your insurance agent sign to verify that you were insured at the time of the accident. Fill in the insurance company name, agency name, and phone number, along with the date of certification, policy number, and the signature of the authorized insurance representative.

6. Finalize the Report

Complete the report by printing the name of the person submitting it, signing it, and dating it. Ensure all information provided is printed in all capital letters using black or blue ink, except for the signatures.

7. Submit the Form

Send the completed form to the Bureau of Motor Vehicles, PFR/Crash Report Section at the address provided on the form. It is important to note that the form should not be sent to the Indiana State Police.