SR 19C, Financial Responsibility Information Request 19 Sr19c
User Manual: SR-19
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SR 19C (REV. 1/2017) WWW
FINANCIAL RESPONSIBILITY INFORMATION REQUEST
Mail To: Department of Motor Vehicles — Financial Responsibility (FR) (916) 657-6677
P.O. Box 942884, Mail Station J237,Sacramento, CA 94284-0884
If a Report of Trafc Accident Occurring in California (SR 1) form was not previously led, you may complete one and attach
it to this form. Law enforcement reports are unacceptable.
SECTION 1 — TYPE OF INFORMATION REQUESTED (Check only one box per request)
Insurance Information from File Uninsured Motorist Certication 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)
Involved as a:
Driver/owner Pedestrian Bicyclist
Passenger Owner of damaged property
Insurance company, representing involved party
Attorney for involved party, who is:
Vehicle driver/owner Pedestrian
Passenger Bicyclist
Other:
STREET ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER
( )
Fill out the information below to have your requester account billed.
VENDOR REQUESTER CODE NUMBER VENDOR AGREEMENT NUMBER
VENDOR NAME
SECTION 3 — ACCIDENT-RELATED OR CLIENT INFORMATION
DATE OF REQUEST FR FILE NUMBER (IF KNOWN) ACCIDENT DATE LOCATION (CITY)
YOUR CLIENT OR INSURED
NAME OF DRIVER OF VEHICLE YOU OR YOUR CLIENT WAS IN
DAMAGE OR INJURY TO
Pedestrian Bicyclist Property Owner
DRIVER LICENSE NUMBER BIRTH DATE 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 le. If the subject is not named on an SR 1 report, information cannot be provided.
did not le an SR 1 report.
was driving a vehicle owned by , an authorized self-insurer (SI # )
or cash deposit certicate holder (CDH ) exempt from the reporting requirement.
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):
contain sufcient information to identify the subject or locate a le. state your interest in the case.
Other:
The FR le 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 le 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 le. An SR 1 must be led.
If you resubmit this request, an additional $20 fee is due.
STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES
®
A Public Service Agency
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Clear Form
SR 19C (REV. 1/2017) WWW
FINANCIAL RESPONSIBILITY INFORMATION REQUEST INSTRUCTIONS
Use this form to request insurance information from our le, an uninsured motorist certicate, or a photocopy of a DMV Report of
Trafc Accident (SR 1) form led 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) Certication; 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” eld. 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 elds, 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 specic location (city) where accident occurred.
•Your Client or Insured – If you are making the request on behalf of yourself, write your name in this eld. 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 eld blank and check the appropriate box in the damage or injury to eld.
–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 certicate.
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 specied 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.
