Sr 1, Report Of Traffic Accident Occuring In California - Dmv
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3DMV USE ONLY
REPORT OF TRAFFIC ACCIDENT
OCCURRING IN CALIFORNIA
A Public Service Agency
READ IMPORTANT INFORMATION ON BACK
AS APPROPRIATE, PLEASE TYPE OR PRINT IN BOXES
# OF VEHICLES DATE OF ACCIDENT
ACCIDENT LOCATION - CITY/COUNTY (CALIFORNIA ONLY)
ON PRIVATE PROPERTY
Yes
No
TIME OF ACCIDENT
DRIVING FOR EMPLOYER
AM
Stopped
Moving
Parked
Pedestrian
Bicyclist
Other
(E.G., ROLLAWAY)
Yes
No
in Traffic
PM
Hour
DRIVER’S NAME (FIRST, MIDDLE, LAST)
DRIVER LICENSE NUMBER
STATE
DRIVER’S STREET ADDRESS
DATE OF BIRTH
CITY
STATE
ZIP CODE
TELEPHONE NUMBERS
Wk (
)
Hm (
)
VEHICLE (YEAR AND MAKE)
VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER
STATE
DAMAGES OVER $750
Yes
No
VEHICLE OWNER—PERSON OR COMPANY
DATE OF BIRTH
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:________________
To:________________
DRIVING FOR EMPLOYER
Moving
Stopped in Traffic
Parked
Pedestrian
Bicyclist
Other
(E.G., ROLLAWAY)
Yes
No
DRIVER’S NAME (FIRST, MIDDLE, LAST)
DRIVER LICENSE NUMBER
STATE
DRIVER’S STREET ADDRESS
DATE OF BIRTH
CITY
STATE
ZIP CODE
TELEPHONE NUMBERS
Wk (
)
Hm (
)
VEHICLE (YEAR AND MAKE)
VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER
STATE
DAMAGES OVER $750
Yes
No
VEHICLE OWNER—PERSON OR COMPANY
DATE OF BIRTH
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:________________
To:________________
NAME AND ADDRESS OF INDIVIDUAL INJURED OR DECEASED
Injured
Driver
Passenger
Deceased
Bicyclist
Pedestrian
NAME AND ADDRESS OF INDIVIDUAL INJURED OR DECEASED
Injured
Driver
Passenger
Deceased
Bicyclist
Pedestrian
OTHER PROPERTY DAMAGED (TELEPHONE POLES, FENCE, LIVESTOCK, ETC.)
DAMAGES OVER $750
Yes
No
PROPERTY OWNER’S NAME AND ADDRESS
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
ADDITIONAL INFORMATION ATTACHED
SR 1 (REV. 9/2008) WWW
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