Form Fr-309 - Traffic Collusion Report
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1
2South Carolina Department of Motor Vehicles
For office use only
__________________________
TRAFFIC COLLISION REPORT
FR-309
Sheet ______ of ______sheet(s)
Not Investigated by Law Enforcement
(Est. 7/05)
According to South Carolina Law 56-5-1270, the driver or owner of a vehicle which is in any manner involved in an accident that is not investigated by law enforcement that
results in total property damages of one thousand dollars or more or in death or bodily injury, shall complete and send this form to South Carolina Department of Motor Vehicles,
Financial Responsibility, P.O. Box 1498, Blythewood, SC 29016-0040 within 15 days of the collision.
Date of collision Day of Week
Time
am County collision occurred
ON what street did it occur:
pm
AT what intersection did it occur, if applicable (street name):
IN what city or town did it occur:
Driver’s Full Name
Street
City
State
Zip Code
Circle Point of
Areas Damaged
1
Date of Birth
Sex
Race
Driver’s License Number
State
Home Phone
Work Phone
2
8
front
Make
VIN
Body
Year
Tag number
State
Legally Parked ? (circle one) Yes / No
3
9
7
Owner’s Name
Street
City
State
Zip Code
4
6
5
Type of Vehicle (circle one): 01- Auto
03- Sta. Wagon
05- TR. Tractor
07- Farm
09- School Bus 11- Motorcycle
Approximate Cost to
02- Bicycle
04- Panel-Pickup 06- Other Truck
08- Comm. Bus
10- Other Bus
12- Other: (Description)____________________________________
Repair: $___________
Other Driver’s or Pedestrian’s Full Name
Street
City
State
Zip Code
Circle Point of
Areas Damaged
1
Date of Birth
Sex
Race
Driver’s License Number
State
Home Phone
Work Phone
2
8
front
Make
VIN
Body
Year
Tag number
State
Legally Parked ? (circle one) Yes / No
3
9
7
Owner’s Name
Street
City
State
Zip Code
4
6
5
Type of Vehicle (circle one): 01- Auto
03- Sta. Wagon
05- TR. Tractor
07- Farm
09- School Bus 11- Motorcycle
Approximate Cost to
02- Bicycle
04- Panel-Pickup 06- Other Truck
08- Comm. Bus
10- Other Bus
12- Other: (Description)____________________________________
Repair: $___________
Damage to property other than vehicle (for example: fence, guardrail, mailbox, building, etc.)
Name of owner
Street
City
State
Zip Code
FR-309a
COMPLETE REVERSE SIDE ALSO
o
Check here if a Form SR-23, Fleet policy of 25 or more vehicles is on file with the Department covering your vehicle.
o
Check here if a certificate of self-insurance has been issued by the department covering your vehicle and indicate the certificate number________________________
o
Check here if liability insurance was not in effect for your vehicle to comply with South Carolina Statutory Requirements.
(If any of the above are applicable, disregard the below portion)
TO THE VEHICLE OWNER:
You are hereby required to return this form to the Department of Motor Vehicles, Financial Responsibility, P.O. Box 1498 Blythewood, SC 29016-0040 with the below
portion completed by an authorized agent or representative of your insurance company showing that on the date and time stated above when the motor vehicle was being
operated, that it was an insured motor vehicle. If the Department does not receive this form within 15 days from the date of the accident, the owner’s registration and/or
driving privileges in this state could be suspended.
TO BE COMPLETED BY INSURANCE AGENCY, BROKER, OR OTHER INSURANCE COMPANY REPRESENTATIVE
I hereby affirm that to the best of my knowledge the policy described below was in effect covering the vehicle listed on the date and time as mentioned.
(Failure to complete all information below will result in refusal of this form)
________________________________________________________________
___________________________________________
Name of Insurance Company
Policy Number
FROM: ____________________________ TO: ________________________________ ____
___________________________________________
Policy Holder
The information as contained herin is based solely upon my knowledge and belief as a representative of the above insurance company and no warranty of
liability is imputed to the above mentioned insurance company as I have listed herein.
____________________________________________________________________________________________
_________________________
Signature of Authorized Representative
Title
Phone Number
NAIC Code Number
*(If insurance agent or broker indicate corresponding company code number assigned by the South Carolina Department of Insurance, indicate whether agent, broker, etc.)
Return this form to: S.C. Department of Motor Vehicles, Form FR-309, Financial Responsibility, Box 1498, Blythewood, SC 29016-0040
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