SR 19C, Financial Responsibility Information Request 19 Sr19c
User Manual: SR-19
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FINANCIAL RESPONSIBILITY INFORMATION REQUEST STATE OF CALIFORNIA Mail To: Department of Motor Vehicles — Financial Responsibility (FR) (916) 657-6677 A Public Service Agency P.O. Box 942884, Mail Station J237,Sacramento, CA 94284-0884 If a Report of Traffic Accident Occurring in California (SR 1) form was not previously filed, you may complete one and attach it to this form. Law enforcement reports are unacceptable. DEPARTMENT OF MOTOR VEHICLES ® SECTION 1 — TYPE OF INFORMATION REQUESTED (Check only one box per request) Insurance Information from File Uninsured Motorist Certification Photocopy of SR 1 Report A nonrefundable $20 fee is required for each document requested. Please enclose a check or provide your requester code information in SECTION 2 directly under your name and address. Please allow 30 days for processing. SECTION 2 — REQUESTER’S INFORMATION NAME Explain your interest in this accident: (Required per California Vehicle Code (CVC) §16005) (Check appropriate box) STREET ADDRESS CITY STATE Involved as a: Driver/owner Pedestrian Bicyclist Passenger Owner of damaged property Insurance company, representing involved party ZIP CODE TELEPHONE NUMBER ( ) Fill out the information below to have your requester account billed. VENDOR REQUESTER CODE NUMBER Attorney for involved party, who is: Vehicle driver/owner Pedestrian Passenger Bicyclist Other: VENDOR AGREEMENT NUMBER VENDOR NAME SECTION 3 — ACCIDENT-RELATED OR CLIENT INFORMATION DATE OF REQUEST FR FILE NUMBER (IF KNOWN) ACCIDENT DATE YOUR CLIENT OR INSURED NAME OF DRIVER OF VEHICLE YOU OR YOUR CLIENT WAS IN DRIVER LICENSE NUMBER BIRTH DATE LOCATION (CITY) DAMAGE OR INJURY TO Pedestrian Bicyclist Property Owner ADDRESS (REQUIRED) SECTION 4 — SUBJECT OF INQUIRY (One name per request) NAME BIRTH DATE ADDRESS DRIVER LICENSE NUMBER VEHICLE LICENSE PLATE NUMBER SUBJECT OF INQUIRY IS Driver of other vehicle Owner of other vehicle SECTION 5 — PERJURY STATEMENT (Required) I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I further certify that I have a proper interest in the case as required by CVC §16005. DATE PRINTED NAME SIGNATURE X FOR DMV USE ONLY The subject of your inquiry: submitted evidence of liability insurance with . is not named in our file. If the subject is not named on an SR 1 report, information cannot be provided. did not file an SR 1 report. was driving a vehicle owned by , an authorized self-insurer (SI # ) ) exempt from the reporting requirement. or cash deposit certificate holder (CDH 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 SR 1 indicates there was no damage over $1,000 ($750 for accidents prior to January 1,2017) and no injury or fatality. Your request does not (please furnish information checked above): state your interest in the case. contain sufficient information to identify the subject or locate a file. Other: The FR file has been purged in accordance with our 48-month purge criteria; insurance information is not available. FR Information Request cannot be processed because SR 1 was received over one year after the accident. No SR 1 report has been received; therefore no file has been established as of . The driver involved in this accident provided DMV with insurance information or was driving an employer’s vehicle. Under these circumstances, the department will not solicit information from the registered owner/employer. The vehicle was reported “Parked;” therefore, insurance information was not solicited. DMV does not maintain insurance for all vehicles registered in California. Insurance information, when needed, is requested upon receipt of an SR 1 following a reportable accident occurring in California. Law enforcement accident reports cannot be used as the basis for establishing an FR file. An SR 1 must be filed. If you resubmit this request, an additional $20 fee is due. SR 19C (REV. 1/2017) WWW Print Clear Form FINANCIAL RESPONSIBILITY INFORMATION REQUEST INSTRUCTIONS Use this form to request insurance information from our file, an uninsured motorist certificate, or a photocopy of a DMV Report of Traffic Accident (SR 1) form filed for a reportable motor vehicle accident occurring in California. Pursuant to CVC §16005, accident information can be released only to individuals who have a proper interest in the accident: a driver, his/her parent, employer, or legal guardian; authorized representatives for these individuals; an injured party; an owner of vehicle/property damaged in the accident; courts; and law enforcement agencies. COMPLETE THE FIELDS AS FOLLOWS: SECTION 1 — TYPE OF INFORMATION REQUESTED Check the appropriate box indicating the type of information you are requesting: Insurance Information from File; Uninsured Motorist (UM) Certification; or Photocopy of SR 1 Report. SECTION 2 — REQUESTER’S INFORMATION Provide the following: • Return Address – Print your name, address, and telephone number (Required). • Vendor Information – If you have a commercial requester account with DMV that entitles you to receive accident information and you wish to have your account billed through Automated Billing Information Service (ABIS) in lieu of remitting the appropriate fee(s), complete the Vendor Requester Code Number, Vendor Agreement Number, and Vendor Name. • Explain Your Interest in This Accident (Required ) – Check the appropriate box to show your interest in this accident. If none of the boxes apply, explain your interest in the “Other” field. In accordance with CVC §16005, DMV will not provide any accident-related information until you establish that you are entitled to it. SECTION 3 — ACCIDENT-RELATED OR CLIENT INFORMATION In the appropriate fields, provide the following information: • Date of Request – Write in the date of your request. • FR File Number – Provide the DMV FR Case number, if known. If not, leave blank. • Accident Date/Location – Complete the accident date and specific location (city) where accident occurred. • Your Client or Insured – If you are making the request on behalf of yourself, write your name in this field. If you represent an individual driver/owner involved in the accident, provide the client’s name. • Name of Driver of Vehicle you or your Client Were in – Write in the name of the individual driving the vehicle your client or insured was driving or riding in (write in your name if you were the driver). – If you or your client were an injured pedestrian or bicyclist, or the owner of property damaged in the accident, leave this field blank and check the appropriate box in the damage or injury to field. – Provide the following information regarding the individual who was driving the car you or your client was in, or the property owner, injured pedestrian, or bicyclist, whichever applies: • Driver License/ID Card Number, Birth Date, and Address (Required) SECTION 4 — SUBJECT OF INQUIRY (One name per request) Complete the name, birth date, address, driver license/ID card number, and license plate number of the person whose insurance information or photocopy of SR 1 you are requesting, or the person for whom you are requesting an uninsured motorist certificate. Indicate by checking the appropriate box whether the subject of inquiry is the driver or the owner of the other vehicle. SECTION 5 — PERJURY STATEMENT (Required) Before any accident-related information can be released, you must declare, under penalty of perjury, that you are entitled to the information and have a proper interest in the case as required under CVC §16005, as specified above. FOR DMV USE ONLY (Do not complete) FEES – A nonrefundable $20 fee is required for each document requested. A separate request form should be used for each item requested; however, if one form is used to request multiple items related to a single accident, each one requires a fee (i.e. $40 for two items, $60 for three, etc.). Please make check or money order payable to DMV. Please allow 30 days for processing. If you have any questions regarding the completion of this form, contact our customer service representatives at (916) 657-6677. SR 19C (REV. 1/2017) WWW
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