Fillable Form Sr 19c - Financial Responsibility Document Request printable pdf download

MAIL THIS TO: DEPARTMENT OF MOTOR VEHICLES—FINANCIAL RESPONSIBILITY

P. O. BOX 942884, MAIL STATION J237, SACRAMENTO, CA 94284-0884

(916) 657-6677

A Public Service Agency

—COMPLETE THE FOLLOWING—

DATE OF REQUEST

THE FEE IS $20 FOR EACH DOCUMENT REQUESTED AND

IS NONREFUNDABLE. PLEASE ENCLOSE A CHECK OR

YOUR REQUESTER CODE NO.

F.R. FILE NO. (IF KNOWN)

YOUR REQUESTER CODE NUMBER.

REQUEST FOR (Please check):

ACCIDENT DATE

LOCATION (CITY)

Insurance information from file

YOUR CLIENT OR INSURED

Uninsured motorist certification

Photocopy of SR1 Report

DRIVER OF CAR YOUR CLIENT OR INSURED WAS IN

DRIVER LICENSE NO.

BIRTH DATE

ADDRESS (REQUIRED)

SUBJECT OF INQUIRY: (one name per request)

NAME

ADDRESS

Please print your name and address in the box above.

Vendor Name _______________________________________

DRIVER LICENSE NO.

BIRTH DATE

Vendor Requester Code No. ___________________________

VEHICLE LICENSE NO.

Vendor Agreement No. ________________________________

FOR DMV USE ONLY

The subject of your inquiry:

has complied with the law by submitting evidence of liability insurance with

__________________________________________________________________________________________

is not named in our file. If the subject is not named on an SR1 report or a police report, an SR19C cannot be processed.

did not file an SR1 report.

was driving a vehicle owned by __________________________________________________________________ .

This company is an authorized self-insurer (SI #_________________) and is 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 SR1 indicates there was

no damage over $750 ($500 if prior to January 1, 2003) or any injury.

Your request does not:

contain sufficient information to identify subject’s driver license number or to locate a possible file. Please furnish

information checked above.

state your interest in the case. Information may only be provided to persons having a proper interest or who were involved

in the accident, per Section 16005(b) V.C. ___________________________________________________________

Other:

The department does not maintain insurance records for all vehicles registered in California. Insurance information is

requested upon receipt of a SR 1 Report of a reportable accident in California.

The FR file has been purged in accordance with our 48-month purge criteria, therefore, the insurance information from the

FR file is no longer available.

SR 1 Traffic Accident Reports, received later than one year from accident date cannot be accepted.

No SR 1 accident report has been received, therefore no file has been established as of _______________________ .

The driver involved in this accident provided the department with insurance information. When a driver has been identified

and provides information, the department will not solicit insurance information from the registered owner.

The vehicle was reported “Parked”, therefore, insurance information was not solicited.

If you resubmit this request, a new $20.00 fee is due.

_______________________________________________________________________________________________

Law enforcement accident reports cannot be used as the basis for establishing a financial responsibility file. The financial

responsibility file can only be established upon receipt of the Financial Responsibility Report of Accident Form (SR 1).

SR 19C (REV. 4/2003) WWW

Form Sr 19c - Financial Responsibility Document Request

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