Sr 19C Form PDF Details

The SR 19C form serves as a critical tool for individuals and entities seeking financial responsibility information following a motor vehicle accident in California. It facilitates the request for insurance details from the Department of Motor Vehicles (DMV) Financial Responsibility sector, providing a structured pathway for acquiring necessary data such as insurance information, uninsured motorist certifications, and photocopies of SR 1 reports. The form stipulates a nonrefundable fee of $20 for each document requested and outlines a specific set of instructions to ensure accurate and complete submissions. Furthermore, the SR 19C form requires requesters to declare their interest in the accident, supporting the DMV’s mandate to release information only to parties with a legitimate claim or involvement according to California Vehicle Code Section 16005. This includes a wide array of potential requesters such as drivers, passengers, pedestrians, bicyclists, attorneys, insurance companies, and owners of damaged property. To use this form, detailed accident-related information and subject of inquiry data must be provided, ensuring the request aligns with the involved parties and specific circumstances of the accident. A perjury statement is also a mandatory component of the form, highlighting the legal obligation of the requester to provide truthful and accurate information. In essence, the SR 19C form is a comprehensive document that underscores the responsibilities and requirements for accessing accident information while safeguarding the privacy and rights of involved individuals.

QuestionAnswer
Form NameSr 19C Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswhat is an sr 19 form, dmv form financial responsibility, dmv client printable, dmv client

Form Preview Example

FINANCIAL RESPONSIBILITY INFORMATION REQUEST

A Public Service Agency

(See instructions on back)

 

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

 

 

 

 

 

 

Explain your interest in this accident:

 

 

 

 

 

 

(Required per California Vehicle Code Section 16005)

 

 

 

 

 

 

(Check appropriate box)

 

 

 

 

 

 

 

 

Involved as a:

 

 

 

 

 

 

 

 

 

 

Driver/owner

Pedestrian

Bicyclist

 

 

 

 

 

 

 

Passenger

Owner of damaged property

Please print your name and address in above box.

 

 

Insurance company, representing involved party

VENDOR REQUESTER CODE NUMBER

 

VENDOR AGREEMENT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attorney for involved party, who is:

 

 

 

 

 

 

 

 

Vehicle driver/owner

 

Pedestrian

VENDOR NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passenger

 

 

Bicyclist

 

 

 

 

 

 

 

Other: ________________________________

Fill out the above information to have your requester account billed.

 

 

 

 

 

 

 

 

SECTION C: ACCIDENT-RELATED INFORMATION

 

 

 

 

 

 

 

 

DATE OF REQUEST

F.R. FILE NUMBER (IF KNOWN)

 

 

ACCIDENT DATE

 

 

LOCATION (CITY)

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR CLIENT OR INSURED

 

 

DRIVER OF CAR YOU OR YOUR CLIENT WAS IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pedestrian

Bicyclist

Property Owner

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

 

BIRTH DATE

 

ADDRESS (REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION D: SUBJECT OF INQUIRY (one name per request)

 

 

 

 

 

 

 

 

NAME

 

 

BIRTH DATE

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

 

VEHICLE LICENSE PLATE NUMBER

 

SUBJECT OF INQUIRY IS

 

 

 

 

 

 

 

 

 

 

Driver of other vehicle

Owner of other vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

_________________________________________________________________________________________________________

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:

• 

Date of Request – Write in the date of your request.

• 

FR File No. – Provide the DMV Financial Responsibility Case number, if known.  If not, leave blank.

• 

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)

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