Form Sr-13c - Safety Responsibility Case - Texas Department Of Public Safety printable pdf download

______________

SAFETY RESPONSIBILITY CASE #

DEPARTMENT OF PUBLIC SAFETY

State of Texas

Exceptions: Filing Evidence of Insurance and original policy

Section 601.333

* If a judgment debtor’s liability insurance company denies responsibility for payment of the judgment, the judgment debtor is

not excused from complying with the judgment provisions of Section 601.333. If the judgment debtor (1) files suit against the

insurer to place responsibility for payment of the judgment upon the insurer and (2) furnishes the Department a certified copy of

the petition, proper insurance coverage is presumed pending final disposition of the suit.

THE STATE OF TEXAS

( )

COUNTY OF ____________

( )

Before me, the undersigned authority in and for said County and State on this the ______ day of ___________________,

A.D. 20_____, personally appeared _____________________________________________________________________

who, after being duly sworn, deposes and say:

There was in effect, at the time _____________________________of the accident out of which the judgment arose a policy of

Date

liability insurance coverage through _________________________________________________________________________

Insurance Company Name

_______________________________covering the operation of the motor vehicle involved. I was insured for the accident upon

Policy Number

which the judgment has been rendered and my insurer is liable to pay such judgment.

STATE REASON WHY INSURANCE COMPANY HAS NOT PAID THE JUDGMENT:

Mark (X) entry applicable:

______ The Insurance Company Became Insolvent (Bankrupt)

______ The Insurance Company was not previously notified; however, they have now been notified and will process the claim.

(We must have a letter from Insurance Company, on their official letterhead, stating claim will be paid).

______ Other: ________________________________________________________________________________________

_________________________________________________________________________________________

Subscribed and sworn to before me, the undersigned authority, on this ______ day of _____________________, A.D. 20_____.

____________________________________

_______________________________________________________

Type or print name of notary

Signature

Notary Public in and for the State of Texas

(Seal)

Attach the original policy or a certified copy thereof and such other documents as may be required to show that the loss, injury

or damage for which the judgment was rendered, was covered by the policy of insurance.

If the Department is satisfied from such papers that the insurer was authorized to issue the policy of insurance in Texas at the

time of issuing the policy and that such insurer is liable to pay such judgment at least to the extent required under Section

601.333, the Safety Responsibility suspension can be withdrawn. (If your insurer became insolvent after the accident, the Safety

Responsibility suspension can be withdrawn.)

SR-13c (Rev. 8/2005)

Form Sr-13c - Safety Responsibility Case - Texas Department Of Public Safety

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