FINANCIAL RESPONSIBILITY INFORMATION REQUEST
A Public Service Agency |
(See instructions on back) |
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MAIL THIS TO: DEPARTMENT OF MOTOR VEHICLES — FINANCIAL RESPONSIBILITY (916) 657-6677
P.O. BOX 942884, MAIL STATION J237, SACRAMENTO, CA 94284-0884
SECTION A: TYPE OF INFORMATION REQUESTED (check only one box per request)
Insurance Information from File |
Uninsured Motorist Certification |
Photocopy of SR 1 Report |
A NONREFUNDABLE $20 FEE IS REQUIRED FOR EACH DOCUMENT REQUESTED. PLEASE ENCLOSE A CHECK OR PROVIDE YOUR REQUESTER CODE INFORMATION IN SECTION B DIRECTLY UNDER YOUR NAME AND ADDRESS.
PLEASE ALLOW 30 DAYS FOR PROCESSING.
SECTION B: REQUESTER’S INFORMATION
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Explain your interest in this accident: |
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(Required per California Vehicle Code Section 16005) |
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(Check appropriate box) |
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Involved as a: |
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Driver/owner |
Pedestrian |
Bicyclist |
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Passenger |
Owner of damaged property |
Please print your name and address in above box. |
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Insurance company, representing involved party |
VENDOR REQUESTER CODE NUMBER |
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VENDOR AGREEMENT NUMBER |
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Attorney for involved party, who is: |
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Vehicle driver/owner |
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Pedestrian |
VENDOR NAME |
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Passenger |
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Bicyclist |
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Other: ________________________________ |
Fill out the above information to have your requester account billed. |
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SECTION C: ACCIDENT-RELATED INFORMATION |
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DATE OF REQUEST |
F.R. FILE NUMBER (IF KNOWN) |
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ACCIDENT DATE |
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LOCATION (CITY) |
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YOUR CLIENT OR INSURED |
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DRIVER OF CAR YOU OR YOUR CLIENT WAS IN |
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Pedestrian |
Bicyclist |
Property Owner |
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DRIVER LICENSE NUMBER |
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BIRTH DATE |
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ADDRESS (REQUIRED) |
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SECTION D: SUBJECT OF INQUIRY (one name per request) |
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NAME |
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BIRTH DATE |
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ADDRESS |
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DRIVER LICENSE NUMBER |
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VEHICLE LICENSE PLATE NUMBER |
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SUBJECT OF INQUIRY IS |
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Driver of other vehicle |
Owner of other vehicle |
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SECTION E: PERJURY STATEMENT (required)
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I further certify that I have a proper interest in the case as required by California Vehicle Code Section 16005.
DATE |
PRINTED NAME |
SIGNATURE |
X
SECTION F: FOR DMV USE ONLY
The subject of your inquiry:
submitted evidence of liability insurance with __________________________________________________________________ .
is not named in our file. If the subject is not named on an SR 1 report, information cannot be provided. did not file an SR 1 report.
was driving a vehicle owned by ______________________________________ , an authorized self-insurer (SI # ____________ )
exempt from the reporting requirement.
has not submitted evidence of liability insurance in effect at the time of the accident.
The accident does not come under the authority of the Financial Responsibility Law; the SR 1 indicates there was no damage over $750 and no injury or fatality.
Your request does not (please furnish information checked above):
contain sufficient information to identify the subject or locate a file. state your interest in the case.
Other:
The FR file has been purged in accordance with our 48-month purge criteria; insurance information is not available.
FR Information Request cannot be processed because SR 1 Traffic Accident Report was received over one year after the accident.
No SR 1 report has been received; therefore no file has been established as of __________________________________________.
The driver involved in this accident provided DMV with insurance information or was driving an employer’s vehicle. Under these circumstances, the department will not solicit information from the registered owner/employer.
The vehicle was reported “Parked;” therefore, insurance information was not solicited.
DMV does not maintain insurance for all vehicles registered in California. Insurance information, when needed, is requested upon receipt of an SR 1 following a reportable accident occurring in California.
Law enforcement accident reports cannot be used as the basis for establishing a FR file. An SR 1 must be filed.
If you resubmit this request, an additional $20 fee is due.
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SR 19 C (REV. 9/2015)
SR 19 C INSTRUCTION SHEET
Use this form to request insurance information from our file, an uninsured motorist certificate, or a photocopy of a DMV Report of Traffic Accident (SR 1) form filed for a reportable motor vehicle accident occurring in California. Pursuant to California Vehicle Code (CVC)
Section 16005, accident information can be released only to individuals who have a proper interest in the accident: a driver, his/ her parent, employer, or legal guardian; authorized representatives for these individuals; an injured party; an owner of vehicle/ property damaged in the accident; courts; and law enforcement agencies.
No information can be provided unless an SR 1 form has been filed with DMV. (If an SR 1 was not previously filed, you may complete one and attach it to the SR 19 C request form).
COMPLETE THE BOXES ON THE SR 19 C FORM AS FOLLOWS:
SECTION A: TYPE OF INFORMATION REQUESTED Check the appropriate box indicating the type of information you are requesting:
Insurance Information from File; Uninsured Motorist (UM) Certification; or Photocopy of SR 1 Report.
SECTION B: REQUESTER’S INFORMATION Provide the following:
• Return Address – In the blank box, print your name and address (required).
• Vendor Information – If you have a commercial requester account with DMV that entitles you to receive accident information and
you wish to have your account billed through Automated Billing Information Service (ABIS) in lieu of remitting the appropriate
fee(s), complete the Vendor Requester Code Number, Vendor Agreement Number, and Vendor Name, in the appropriate fields
directly under the return address box.
• Explain Your Interest in This Accident (required) – Check the appropriate box to show your interest in this accident. If none of the
boxes apply, explain your interest in the “Other” field. In accordance with CVC §16005, DMV will not provide any accident-related information until you establish that you are entitled to it.
SECTION C: ACCIDENT-RELATED INFORMATION In the appropriate boxes, provide the following information:
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Date of Request – Write in the date of your request. |
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FR File No. – Provide the DMV Financial Responsibility Case number, if known. If not, leave blank. |
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Accident Date/Location – Complete the accident date and specific location (city) where accident occurred. |
• Your Client or Insured – If you are making the request on behalf of yourself, write your name in this box. If you represent an individual driver/owner involved in the accident, provide the client’s name.
• Driver of Car You or Your Client Was In – Write in the name of the individual driving the car your client or insured was driving or riding in (write in your name if you were the driver).
• If you or your client were an injured pedestrian or bicyclist, or the owner of property damaged in the accident, leave the above
field blank and check the appropriate box in the field directly to the right.
• In the next three boxes, provide the following information regarding the individual who was driving the car you or your client was in, or the property owner, injured pedestrian, or bicyclist, whichever applies:
• Driver License/ID Card Number, Birth Date, and Address (required)
SECTION D: SUBJECT OF INQUIRY (Other Party) Complete the name, birth date, address, driver license/ID card number, and
license plate number of the person whose insurance information or photocopy of SR 1 you are requesting, or the person for whom you are requesting an uninsured motorist certificate. Indicate by checking the appropriate box whether the subject of inquiry is the driver or
the owner of the other vehicle.
SECTION E: PERJURY STATEMENT (Required) Before any accident-related information can be released, you must declare, under penalty of perjury, that you are entitled to the information and have a proper interest in the case as required under CVC §16005, as specified above.
SECTION F: FOR DMV USE ONLY The bottom portion of the SR 19 C request form is for DMV Use Only.
FEES: A nonrefundable $20 fee is required for each document requested. A separate request form should be used for each item requested; however, if one form is used to request multiple items related to a single accident, each one requires a fee (i.e. $40 for two items, $60 for three, etc.). Please make check or money order payable to DMV.
Please allow 30 days for processing. If you have any questions regarding the completion of this form, contact our customer service representatives at (916) 657-6677.
SR 19 C (REV. 9/2015)
