Form Sr 1a - California Traffic Accident Report
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1
2PLEASE READ IMPORTANT INFORMATION ON BACK
DMV USE ONLY
CALIFORNIA TRAFFIC ACCIDENT REPORT
A Public Service Agency
DEPARTMENT OF MOTOR VEHICLES—FINANCIAL RESPONSIBILITY
P. O. BOX 942884 MAIL STA. J237, SACRAMENTO, CALIFORNIA 94284-0884
(916) 657-6677
PLEASE PRINT OR TYPE
DATE AND LOCATION OF ACCIDENT
DATE OF ACCIDENT
TIME OF ACCIDENT
NUMBER OF VEHICLES
FATALITY
Month:
Day:
Year:
A.M.
P.M.
YES
NO
LOCATION (NEAREST STREET OR HIGHWAY)
(CALIFORNIA ONLY)
ON PRIVATE PROPERTY
City:
County:
YES
NO
REPORTING PARTY (Also, complete Part A below)
Moving
Stopped in Traffic
Parked
Pedestrian
Bicyclist
Other (Explain): ________________________________
DRIVER’S NAME (FIRST, MIDDLE, LAST)
DRIVER LICENSE NUMBER
STATE
DATE OF BIRTH
Month:
Day:
Year:
DRIVER’S ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
Work (
)
Home (
)
OWNER OF VEHICLE (FIRST, MIDDLE, LAST)
ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
VEHICLE (YEAR AND MAKE)
VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER
STATE
DAMAGES OVER $500?
YES
NO
WERE YOU DRIVING A VEHICLE OWNED BY YOUR EMPLOYER DURING THE COURSE OF EMPLOYMENT?
IF YES, GIVE NAME AND ADDRESS OF EMPLOYER:
YES
NO
REPORTING PARTY’S INSURANCE INFORMATION
DMV USE ONLY
WAS A LIABILITY INSURANCE POLICY IN EFFECT FOR THE VEHICLE INVOLVED IN THIS ACCIDENT?
YES
NO
NAME OF INSURANCE COMPANY (NOT AGENCY OR BROKERAGE) AT THE TIME OF THE ACCIDENT
POLICY NUMBER
POLICY HOLDER’S NAME AND ADDRESS
POLICY PERIOD
From:
To:
OTHER PARTY
Moving
Stopped in Traffic
Parked
Pedestrian
Bicyclist
Other (Explain): ________________________________
DRIVER’S NAME (FIRST, MIDDLE, LAST)
DRIVER LICENSE NUMBER
STATE
DATE OF BIRTH
Month:
Day:
Year:
DRIVER’S ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
Work (
)
Home (
)
OWNER OF VEHICLE (FIRST, MIDDLE, LAST)
ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
VEHICLE (YEAR AND MAKE)
VEHICLE LICENSE PLATE OR VEHICLE IDENTIFICATION NUMBER
STATE
DAMAGES OVER $500?
YES
NO
WAS HE/SHE DRIVING A VEHICLE OWNED BY HIS/HER EMPLOYER DURING THE COURSE OF EMPLOYMENT?
IF YES, GIVE NAME AND ADDRESS OF EMPLOYER:
YES
NO
OTHER PARTY’S INSURANCE INFORMATION
DMV USE ONLY
WAS LIABILITY COVERAGE IN EFFECT FOR THE VEHICLE AT OF THE TIME THE ACCIDENT
YES
NO
NAME OF INSURANCE COMPANY (NOT AGENCY OR BROKERAGE) AT THE TIME OF THE ACCIDENT
POLICY NUMBER
POLICY HOLDER’S NAME AND ADDRESS
POLICY PERIOD
From:
To:
INJURIES AND/OR DEATHS CAUSED BY THE ACCIDENT
NAME AND ADDRESS
Under
Driver
In Your Vehicle
Bicyclist
Injury
Fatal
Age 18
Passenger
In Other Vehicle
Pedestrian
NAME AND ADDRESS
Under
Driver
In Your Vehicle
Bicyclist
Injury
Fatal
Age 18
Passenger
In Other Vehicle
Pedestrian
DAMAGE TO OTHER PROPERTY (Telephone poles, fences, livestock, etc.)
PROPERTY OWNER’S NAME, ADDRESS AND DRIVER LICENSE NUMBER
DAMAGES OVER $500?
YES
NO
I certify under penalty of perjury under the laws of the State of California that the information entered by me on the document is true and correct.
DATE
PRINT NAME
SIGN NAME
X
X
PLEASE USE ADDITIONAL SR-1 CALIFORNIA TRAFFIC ACCIDENT REPORT FORMS TO REPORT OTHER INVOLVED PARTIES
SR 1 (REV. 4/99)
CALIFORNIA INSURANCE INFORMATION
DO NOT DETACH
DMV FILE NUMBER
YOUR
A
The Department may send this part to the insurance company indicated. If not fully completed, it will
VEHICLE
be assumed you were not insured for the accident and your license will be suspended.
NAME OF INSURANCE COMPANY (NOT AGENCY OR
BROKERAGE) THAT ISSUED THE LIABILITY POLICY
COVERING THE OPERATION OF YOUR VEHICLE
POLICY NUMBER
POLICY PERIOD
I
DRIVER LICENSE NUMBER
From:
To:
(DRIVER OF YOUR VEHICLE)
N
DATE OF ACCIDENT
IN OR NEAR (CITY OR TOWN) (CALIFORNIA ONLY)
S
U
MAKE OF YOUR VEHICLE
TYPE
YEAR
VEHICLE IDENTIFICATION NUMBER
VEHICLE LICENSE PLATE NUMBER
STATE
R
A
N
DRIVER
ADDRESS
C
E
OWNER
ADDRESS
FULL NAME OF POLICY HOLDER
ADDRESS
SR 1A (REV. 4/99) WWW
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