Sr1 Form Nevada – Fill Out and Use This PDF

555 Wright Way

Carson City, NV 89711

Reno/Sparks/Carson City (775) 684-4DMV (4368)

Las Vegas Area (702) 486-4DMV (4368)

Rural Nevada (877) 368-7828

Website: www.dmvnv.com

REPORT OF TRAFFIC ACCIDENT

(NRS 484.229, 484.236)

INSTRUCTIONS:

Pursuant to NRS 484.229, this SR-1 report needs to be completed within 10 days after an accident that occurred in the State of Nevada and was NOT investigated at the scene by law enforcement. Please complete ALL sections. This report cannot be accepted or processed unless ALL information has been completed for ALL DRIVERS AND VEHICLES that were involved in the accident.

THE FOLLOWING ATTACHMENTS MUST BE INCLUDED (this SR-1 report will be considered VOID if not attached):

(1)a copy of your insurance that was in effect on the date of the accident for the vehicle involved;

(2)an estimate of repairs or a statement of total loss if there was $750 or more in vehicle or property damage (of any one person); and

(3)a doctor’s statement of injury for each person injured in your vehicle (if the accident resulted in bodily injury or death).

Once completed, please sign your name on the second page, attach all required documents, and mail the complete report to the DMV at the above address. Only reports that have been properly completed for all drivers and vehicles, and include the required attachments, will be accepted and processed. Any SR-1 report that is incomplete or does not meet the requirements of NRS 484.229, as specified above, will not be retained by the Department. Failure to submit this report after it has been requested by the Department of Motor Vehicles may result in the suspension of your driving privilege for up to one year (per NRS 484.236).

ACCIDENT INFORMATION:

Date and time of accident:

DateDay of WeekTime

LOCATION WHERE THE ACCIDENT OCCURRED:

Highway No. or Street Name

City

County

DRIVER AND VEHICLE INFORMATION:

If more than two vehicles were involved, please provide the additional driver and vehicle information on a separate page. NOTE: Plate number only will NOT be accepted.

No. 1

Driver

Pedestrian

Parked Vehicle

Pedal Cyclist

Other

No. 2

Driver

Pedestrian

Parked Vehicle

Pedal Cyclist

Other

1-

2-

3-

4-

5-

1-

2-

3-

4-

5-

Name (LAST, FIRST, MIDDLE)

Name (LAST, FIRST, MIDDLE)

Street Address

City

State

Zip

Street Address

City

State

Zip

Driver License No. and State

Date of Birth (MM/DD/YYYY)

Driver License No. and State

Date of Birth (MM/DD/YYYY)

License Plate No. and State

Year and Make

License Plate No. and State

Year and Make

Body Type

Vehicle ID No.

Body Type

Vehicle ID No.

OWNER’S INFORMATION: If the driver and owner of the vehicle are the same, please print “Same as Above.”

No. 1

No. 2

SR-1 (Revised 04/2008)

INSURANCE INFORMATION:

A COPY OF YOUR INSURANCE CARD MUST BE ATTACHED TO THIS REPORT.

Please ensure to attach a copy of your insurance card that was in effect on the date of the accident for the vehicle involved. This information is necessary to verify that the vehicle was insured at the time of the accident. If insurance was not in effect on the date of the accident, your driving privilege and registration may be suspended under Chapter 485 of Nevada Revised Statutes.

ACCIDENT DESCRIPTION

Please write a brief description of the accident:

PROPERTY DAMAGE (other than the vehicle):

If you answer “Yes” below, please explain in the space provided:

Property Owner’s Name:

Property Owner’s Address:

ESTIMATE OF REPAIRS:

AN ESTIMATE OF REPAIRS OR A STATEMENT OF TOTAL LOSS MUST BE ATTACHED if there was $750 or more in vehicle or property damage (of any one person). Pursuant to NRS 484.229, the estimate of repairs or statement of total loss must be from an established repair garage, an insurance adjuster employed by an insurer licensed to do business in the State of Nevada, an adjuster licensed pursuant to chapter 684A of NRS, or an appraiser licensed pursuant to Chapter 684B of NRS.

This SR-1 report will be considered VOID if not attached.

PERSONAL INJURY:

If an injury occurred, A DOCTOR’S STATEMENT OF INJURY FOR EACH INDIVIDUAL INJURED IN YOUR VEHICLE MUST BE ATTACHED. VOID if not attached!

Name						Age		Sex
Street Address		City		State		Zip Code		Relationship to Driver of Your Vehicle*
								*Husband, wife, son, daughter, etc.
Nature and Extent of Injuries

SIGNATURE:

By completing this report, you are authorizing the Department of Motor Vehicles to release your name, mailing address, and insurance information to the other parties involved in the traffic accident and/or to their insurer (NRS 484.229).

I hereby certify all statements made in this report are true. I agree and understand any person who completes this report knowing or having reason to believe the information is false is guilty of a gross misdemeanor. (NRS 484.236)

Signature

Date Signed

*** VOID IF NOT SIGNED ***

NOTE: Only reports that have been properly completed for all drivers and vehicles, and include the required attachments, will be accepted and processed. Any SR-1 report that is incomplete or does not meet the requirements of NRS 484.229, as specified above, will not be retained by the Department.

SR-1 (Revised 04/2008)