Sr 1 Form PDF Details

Are you looking for guidance to help you fill out SR 1 Form and understand the ins-and-outs of insurance? The SR 1 Form is the form used in California to report a motor vehicle accident, and it’s important that all parties involved know how to accurately fill one out. In this blog post we will provide an overview of what information needs to be included when filing an SR 1 Form, as well as advice on understanding different forms associated with auto insurance policies so you can make sure you’re prepared in case of an emergency. Read on for more helpful tips!

QuestionAnswer
Form NameSr 1 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmotor vehicle sr 1, arkansas motor accident report, ar accident report, arkansas vehicle accident report

Form Preview Example

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: ____________________________________/_______

_________________________________________________________________________________________________________________________________________

Street address

City

 

State

Zip Code

 

 

 

 

 

Mailing address

City

 

State

Zip Code

Owner’s Name: __________________________________________________

_______________________________________________________________________

 

Make

Year

License Plate #

State

_________________________________________________________________________________________________________________________________________

Street address

City

State

Zip Code

 

 

 

 

Mailing address

City

State

Zip Code

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):

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

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: ____________________________________/_______

_________________________________________________________________________________________________________________________________________

Street address

City

 

State

Zip Code

 

 

 

 

 

Mailing address

City

 

State

Zip Code

Owner’s Name: __________________________________________________

_______________________________________________________________________

 

Make

Year

License Plate #

State

_________________________________________________________________________________________________________________________________________

 

Street address

City

State

Zip Code

 

 

 

 

 

 

 

 

Mailing address

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

The information contained on this report is true and correct to the best of my knowledge and belief.

 

 

 

 

Signature: __________________________________________________________________________________

Date: ____________________________________

 

 

 

 

 

 

 

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.

Insurance Agent Only

VERIFICATION OF LIABILITY INSURANCE (SR-21) Insurance Agent Only

Description of Vehicle in Accident: ________________________________________________________________________________________________

Year

Make

Model

License Plate Number or VIN (Vehicle Identification Number)

Owner’s Name: _______________________________________________________

Operator’s Name:__________________________________________________

Owner’s Address: _____________________________________________________

Operator’s Address: ________________________________________________

Owner’s Mailing Address: ______________________________________________

Operator’s Mailing Address: _________________________________________

Insurance Company Name: ___________________________________________

 

Agent’s Name: ____________________________________________________

Insurance Co. Address: ________________________________________________________________________ Phone Number: (

) _______________________

E-Mail Address: _________________________________________________________________________________________________________________________

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

 

Coverage applies to: ___________ owner

__________ operator

 

SR Case #: ______________________ Date of Accident: ______________

Signature of Authorized Representative: _____________________________________________ Date: ____________________________________