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Report Of Traffic Accident Occuring In California SR 1 - California

Report Of Traffic Accident Occuring In California Form. This is a California form and can be used in Accident Involvement (DMV) Statewide .
 Fillable pdf Last Modified 7/9/2013
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A Public Service Agency REPORT OF TRAFFIC ACCIDENT OCCURRING IN CALIFORNIA READ IMPORTANT INFORMATION ON BACK ACCIDENT LOCATION - CITY/COUNTY (CALIFORNIA ONLY) DMV USE ONLY AS APPROPRIATE, PLEASE TYPE OR PRINT IN BOXES # OF VEHICLES DATE OF ACCIDENT ON PRIVATE PROPERTY Yes TIME OF ACCIDENT No No REPORTING PARTY'S INFORMATION Hour AM PM Moving Stopped in Traffic DRIVING FOR EMPLOYER Parked Pedestrian Bicyclist Other (E.G., ROLLAWAY) DRIVER LICENSE NUMBER Yes STATE DRIVER'S NAME (FIRST, MIDDLE, LAST) DRIVER'S STREET ADDRESS DATE OF BIRTH CITY STATE ZIP CODE TELEPHONE NUMBERS Wk ( VEHICLE (YEAR AND MAKE) VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER ) STATE Hm ( ) DAMAGES OVER $750 Yes VEHICLE OWNER--PERSON OR COMPANY DATE OF BIRTH No ADDRESS CITY STATE ZIP CODE INSURANCE COMPANY NAME (NOT AGENT OR BROKER) AT THE TIME OF THE ACCIDENT POLICY NUMBER COMPANY NAIC NUMBER POLICY PERIOD POLICY HOLDER NAME From:________________ Moving Stopped in Traffic Parked To:________________ DRIVING FOR EMPLOYER Pedestrian Bicyclist Other (E.G., ROLLAWAY) DRIVER LICENSE NUMBER Yes STATE No DRIVER'S NAME (FIRST, MIDDLE, LAST) OTHER PARTY'S INFORMATION DRIVER'S STREET ADDRESS DATE OF BIRTH CITY STATE ZIP CODE TELEPHONE NUMBERS Wk ( VEHICLE (YEAR AND MAKE) VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER ) STATE Hm ( ) DAMAGES OVER $750 Yes VEHICLE OWNER--PERSON OR COMPANY DATE OF BIRTH No ADDRESS CITY STATE ZIP CODE INSURANCE COMPANY NAME (NOT AGENT OR BROKER) AT THE TIME OF THE ACCIDENT POLICY NUMBER COMPANY NAIC NUMBER POLICY PERIOD POLICY HOLDER NAME From:________________ NAME AND ADDRESS OF INDIVIDUAL INJURED OR DECEASED To:________________ Injured Driver Bicyclist Passenger Pedestrian INJURY/DEATH PROPERTY DAMAGE Deceased NAME AND ADDRESS OF INDIVIDUAL INJURED OR DECEASED Injured Deceased OTHER PROPERTY DAMAGED (TELEPHONE POLES, FENCE, LIVESTOCK, ETC.) Driver Bicyclist DAMAGES OVER $750 Passenger Pedestrian Yes PROPERTY OWNER'S NAME AND ADDRESS No I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. DATE PRINTED NAME SIGNATURE X SR 1 (REV. 9/2008) WWW ADDITIONAL INFORMATION ATTACHED A I N S U R A N C E YOUR VEHICLE CALIFORNIA INSURANCE INFORMATION The Department may send this part to the insurance company indicated. If not fully completed, it will be assumed you were not insured for the accident and your license will be suspended. DO NOT DETACH DMV FILE NUMBER NAME OF INSURANCE COMPANY (NOT AGENCY OR BROKERAGE) THAT ISSUED THE LIABILITY POLICY COVERING THE OPERATION OF YOUR VEHICLE POLICY NUMBER POLICY PERIOD From: DATE OF ACCIDENT IN OR NEAR (CITY OR TOWN) (CALIFORNIA ONLY) To: DRIVER LICENSE NUMBER (DRIVER OF YOUR VEHICLE) VEHICLE (YEAR AND MAKE) VEHICLE IDENTIFICATION NUMBER VEHICLE LICENSE PLATE NUMBER STATE DRIVER ADDRESS OWNER ADDRESS FULL NAME OF POLICY HOLDER ADDRESS SR 1A (REV. 9/2008) WWW If the policy was not in effect, this form must be completed and returned to the Department within 20 days. The undersigned company advises that with respect to the reported accident, the policy reported on the reverse side: WAS NOT IN EFFECT Was not a liability policy Policy Number Signature Title Date Did not cover the vehicle/driver Number is not a company policy number Policy Period from to MAIL TO: Department of Motor Vehicles Financial Responsibility P. O. Box 942884 Sacramento, CA 94284-0884 SR 1A (REV. 9/2008) WWW IMPORTANT INFORMATION California law requires traffic accidents on a California street/highway or private property to be reported to the Department of Motor Vehicles (DMV) within 10 days if there was an injury, death or property damage in excess of $750. Untimely reporting could result in DMV suspending a driver license. Accidents involving vehicles not required to be registered such as an off-road vehicle (OHV), implement of husbandry, or snowmobile or occurring on a military base or occurring on the driver's own property involving only the personal property of the driver and there was no injury or death are not reportable. The law requires the driver to file this SR-1 form with DMV regardless of fault. This report must be made in addition to any other report filed with a law enforcement agency, insurance company, or the California Highway Patrol (CHP) as their reports do not satisfy the filing requirement. An insurance agent, attorney, or other designated representative may file the report for the driver. The law requires every driver and every owner of a motor vehicle to be "financially responsible" for any injury or damage resulting from operating or owning a motor vehicle. The minimum insurance level for "financial responsibility" is public liability and property damage coverage of $15,000 for injury or death of one person, $30,000 for injury or death of two or more persons and $5,000 property damage per accident. Comprehensive and collision insurance does not meet the legal requirement. §1806 of the California Vehicle Code (CVC) requires the DMV to record accident information regardless of fault when individuals report accidents under the Financial Responsibility Law or if law enforcement agencies or CHP investigate and make a report. wheN COMPleTINg ThIS FORM... Please print within the spaces and boxes on this form. If you need to provide additional information on a separate piece of paper(s) or you include a copy of any law enforcement agency report, please check the box to indicate `Additional Information Attached'. If you are the passenger reporting the accident, be sure to identify yourself by using the `other' box and stating `passenger' in the explanation. · · · · · Write unk (for unknown) or none in any space or box when you do not have information on the other party involved. Give insurance information that is complete and which correctly and fully identifies the company that issued the policy. Place the correct National Association of Insurance Commissioners (NAIC) number for your insurance company in the boxes provided. The NAIC number should be located on your insurance ID card or you can contact your insurance agent or company for the information. Identify any person involved in the accident (driver, passenger, bicyclist, pedestrian, etc.) who you saw was injured or complained of bodily injury or know to be deceased. Record in the OTHER PROPERTY DAMAGED section any damage to telephone poles, fences, street signs, guard posts, trees, livestock, dogs, etc., meeting the filing
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