ARKANSAS MOTOR VEHICLE ACCIDENT REPORT (SR-1)
NOTICE: This report must be filed within thirty (30) days of accident.
For reporting motor vehicle accidents which result in damage to the property of any one person in excess of $1,000.00 or in bodily injury to or in the death of any one person.
SAFETY RESPONSIBILITY SECTION
P.O. Box 1272, Rm. 1120
Little Rock, AR 72203
Phone number: (501) 682-7100
Fax number: (501) 682-2100
S.R. Case Number: (Office Use Only)
YOUR VEHICLE DRIVER INFORMATION:
Driver’s Name: ____________________________________________________ Driver’s License Number/State: ____________________________________/_______
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E-Mail Address: ____________________________________________________________________________________________________________________________
ACCIDENT INFORMATION:
Accident location (city/town): ___________________ Street/Roadway/HWY Accident occurred: ______________________ Time of Accident: ___________AM or PM
Date of Accident: ______________ 20___ Cost of repairing your vehicle/property: $_________________ Cost of repairing other vehicle: $ _______________________
Description of Accident (attach other pages if necessary):
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FATALITIES/INJURIES TO PERSONS IN YOUR VEHICLE:
(List names or person(s) injured or killed in accident. )
Name: __________________________________ Name: ___________________________________ Name:____________________________________________
OTHER VEHICLE DRIVER INFORMATION:
Driver’s Name: ____________________________________________________ Driver’s License Number/State: ____________________________________/_______
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The information contained on this report is true and correct to the best of my knowledge and belief. |
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Signature: __________________________________________________________________________________ |
Date: ____________________________________ |
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Please note that the Verification of Liability Insurance (SR21) is located on the back of this form and must be completed by an authorized insurance agent.
INSTRUCTIONS
A.Who must report. The driver of every motor vehicle who is involved in any accident within the State which results in damage to the property of any one person in excess of $1,000.00 or which causes the injury or death of any person regardless of who is at fault. This report must be filed within thirty (30) days of the accident.
(1)If driver injured. If the driver is incapacitated by injuries received in the accident, the owner
(if the driver and owner are different persons) shall report. If, however, the driver and owner are the same person, the driver will be excused from reporting during this period of his injury.
B.Reports of Investigating Officers. These reports are not filed with the Department of Finance and Administration. The driver will, however, find the officer’s report useful as a source of information.
C.Filing out this report. Do not insert indefinite information. Example: DO NOT insert “TOTAL LOSS”. Show the amount it will cost to replace the vehicle. For hit and run accidents, where the offending driver and owner are not known to anyone, insert “Hit and Run”. Where there are more than two vehicles involved in an accident, attach an additional report for each additional vehicle.
D.Proof of Financial Responsibility. The law requires that the driver and/or owner of every vehicle involved in the accident to file proof of financial responsibility with the Department of Finance and Administration within thirty (30) days after the accident. This proof of financial responsibility can be filed only in the following manner provided by the law.
(1)Proof of Insurance. The SR-21 must show limits of $25,000, $50,000 and $25,000, or state that the limits at least equal those required by this State (Arkansas).
(2)A deposit of security as tabulated by this Department.
(3)A written release of liability signed by the other party in the accident.
(4)A final civil adjudication of non-liability from a court of competent jurisdiction. Trial in traffic court is not an adjudication of non-liability.
(5)A covenant not to sue. Must be in writing and signed by the adverse party and notarized.
(6)A written agreement which has been accepted by the appropriate parties to the payment of damages in installments.
(7)Proof that the adverse party or his liability insurance carrier have reimbursed you for
your property damage.
(8)A written request to this Department for a hearing to determine if there is a reasonable possibility that a judgment may be rendered against you as a result of the accident. If the hearing indicates such judgment does not seem likely, then the Department of may not require the security deposit.
(9)A copy of the bankruptcy petition with a list of creditors naming all parties.
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Insurance Agent Only |
VERIFICATION OF LIABILITY INSURANCE (SR-21) Insurance Agent Only |
Description of Vehicle in Accident: ________________________________________________________________________________________________ |
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Owner’s Name: _______________________________________________________ |
Operator’s Name:__________________________________________________ |
Owner’s Address: _____________________________________________________ |
Operator’s Address: ________________________________________________ |
Owner’s Mailing Address: ______________________________________________ |
Operator’s Mailing Address: _________________________________________ |
Insurance Company Name: ___________________________________________ |
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Agent’s Name: ____________________________________________________ |
Insurance Co. Address: ________________________________________________________________________ Phone Number: ( |
) _______________________ |
E-Mail Address: _________________________________________________________________________________________________________________________
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Was limited liability insurance in place at the time of accident? |
______ yes |
_____no |
Policy Number: _____________________________________ |
Liability Limits equal or higher to Arkansas requirements? |
______ yes |
_____no |
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Coverage applies to: ___________ owner |
__________ operator |
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SR Case #: ______________________ Date of Accident: ______________ |
Signature of Authorized Representative: _____________________________________________ Date: ____________________________________
