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Indiana Sr21 Sample

INDIANA OPERATOR’S PROOF OF INSURANCE/CRASH REPORT

STATE FORM 52441 (R / 2-06) / SR21

Collision Date

 

Day of Week

Actual Local Time

AM

# of Vehicles

Reporting Officer Name

 

Badge #

Send form to Bureau

MONTH

DAY

 

YEAR

 

 

 

 

PM

 

 

 

 

 

 

of Motor Vehicles.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do not send to

County where crash occurred

 

Nearest City/Town

Was Officer Report

Reporting Police Agency Name

 

 

Indiana State Police.

 

 

 

 

 

 

 

 

Taken?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Road Collision Occurred On:

 

Nearest Intersecting Road:

 

Direction and distance to nearest intersection:

Local ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured

Print Driver’s Name (Last, First, MI)

 

 

 

Driver’s License Number

 

 

 

 

 

 

 

 

 

 

 

 

Address (Number, Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex

 

 

 

DATE OF BIRTH

 

License Type

 

License State

 

Month

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Owner’s Name & Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Veh. Yr.

 

Make

Model

 

Lic. Yr.

Lic. Plate #

Lic. State

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Drivers Involved

Print Driver’s Name (Last, First, MI)

Driver’s License Number

Sex

 

DATE OF BIRTH

 

 

Month

Day

Year

 

 

 

 

 

Print Driver’s Name (Last, First, MI)

 

 

 

 

 

 

 

 

 

Driver’s License Number

Sex

 

DATE OF BIRTH

 

 

Month

Day

Year

 

 

 

 

 

Print Driver’s Name (Last, First, MI)

 

 

 

 

 

 

 

 

 

Driver’s License Number

Sex

 

DATE OF BIRTH

 

 

Month

Day

Year

 

 

 

 

 

Name of Person Submitting This Report

Date Signed

Signature

THIS SECTION MUST CONTAIN THE SIGNATURE OF YOUR INSURANCE AGENT, IF YOU HAD INSURANCE AT THE TIME OF THE COLLISION. The company signatory hereto gives notice that its policy issued to the above named insured is a motor vehicle liability policy approved by the Commissioner of Insurance of the State of Indiana and was in effect on the date of the above described collision. A signature by an insurance agent or authorized representative is verification that the above driver (Insured) was insured at the time of the collision. Omission of agent signature signifies the driver was NOT insured at the time of the collision.

Insurance Company

Agency Name

Phone #

Date of Certification

Insured’s Policy Number

Signature of Authorized Insurance Representative

Date

Instructions for Completing the Indiana Operator’s Crash Report

Collisions resulting in injury, death or damage of $1000 or more (as determined by the reporting officer) must be reported on this form within 10 days. PRINT ALL INFORMATION USING ALL CAPITAL LETTERS (except your signature). Complete in black or blue INK.

Answer all questions to the best of your knowledge. If you are unable to answer any question, mark “unknown” or “U”. If the answer does not apply, mark with a slash (\) through the box.

YOU ARE THE INSURED. LIST THE DRIVER INFORMATION FOR ALL OTHER DRIVERS INVOLVED IN THE COLLISION UNDER “OTHER DRIVERS INVOLVED”.

If you were insured at the time of the collision, you must have the signature of the insurance agent before mailing the report.

Please submit this report to:

Bureau of Motor Vehicles

Important! PFR/Crash Report Section

Send to: P.O. Box 7169

Indianapolis, IN 46207

BY LAW, YOUR REPORT IS CONFIDENTIAL AND CANNOT BE USED AS EVIDENCE IN ANY TRIAL IC 9-26-3-4

The driver of any motor vehicle involved in a crash that results in injury or death or total property damage of $1000 or more must make a report on this form within ten

(10)days. The failure or refusal of any person to report a crash as required is cause for the suspension or revocation of the operator’s or chauffeur’s license and vehicle registration of such person. Such failure or refusal is also a misdemeanor. If the driver is physically incapable of making the report, any occupant of the vehicle is required to do so. A witness may also be required to make a report. A supplementary report will be required whenever an original report is insufficient.

The purpose of this report is to obtain information necessary to the administration of the Safety Responsibility Law and to obtain data useful in crash prevention. Complete and clear answers to all the questions are necessary. An accurate original report will avoid the necessity for supplementary reports. If you have difficulty in filling in the report, consult your nearest police authority or Bureau of Motor Vehicles at (317) 232-2840.

File Characteristics

Fact Name Details
Form Title Indiana Operator’s Proof of Insurance/Crash Report
Form Number State Form 52441 (R / 2-06) / SR21
Collision Reporting Requirement Must be reported within 10 days for crashes resulting in injury, death, or property damage of $1,000 or more.
Submission Address Bureau of Motor Vehicles, P.O. Box 7169, Indianapolis, IN 46207
Confidentiality Clause The report is confidential and cannot be used as evidence in any trial (IC 9-26-3-4).
Insurance Agent Signature Requirement Required if insured at the time of the collision; absence signifies no insurance.
Governing Law Indiana Code IC 9-26-3-4 outlines the legal obligations for crash reporting.

Essential Points on This Form

  1. What is the Indiana SR21 form?

    The Indiana SR21 form is an official document used to report motor vehicle collisions that result in injury, death, or property damage of $1,000 or more. It serves as proof of insurance and is required to be submitted to the Bureau of Motor Vehicles within ten days of the incident.

  2. Who is required to fill out the SR21 form?

    The driver of any motor vehicle involved in a crash meeting the criteria mentioned above must fill out the SR21 form. If the driver is unable to complete the report due to physical incapacity, any occupant of the vehicle can do so. Witnesses may also be required to report the incident.

  3. When should the SR21 form be submitted?

    The SR21 form must be submitted within ten days of the collision. Timely submission is crucial, as failure to report can lead to the suspension or revocation of your driver's license and vehicle registration.

  4. What information is required on the SR21 form?

    You'll need to provide a variety of details, including:

    • The date and time of the collision
    • The names and addresses of all drivers involved
    • The insurance information for the driver
    • Details about the vehicles, such as make, model, and license plate number
    • The location of the collision

    Make sure to answer all questions to the best of your ability. If something is unknown, mark it as such.

  5. What happens if I don't submit the SR21 form?

    Failing to submit the SR21 form can result in serious consequences, including the suspension or revocation of your driver's license and vehicle registration. Additionally, it may be classified as a misdemeanor.

  6. Do I need my insurance agent's signature on the SR21 form?

    If you were insured at the time of the collision, you must obtain your insurance agent's signature on the form. This signature verifies that you were insured at the time of the incident. Without it, the form may not be accepted.

  7. How should I complete the SR21 form?

    When filling out the SR21 form, use all capital letters and complete it in black or blue ink. Answer all questions clearly, and if an answer does not apply, indicate this with a slash through the box. If you cannot answer a question, write "unknown" or "U."

  8. Where do I send the completed SR21 form?

    The completed SR21 form should be mailed to the Bureau of Motor Vehicles at the following address:

    P.O. Box 7169
    Indianapolis, IN 46207

  9. What if I need help filling out the SR21 form?

    If you encounter difficulties while completing the SR21 form, you can consult your nearest police authority or contact the Bureau of Motor Vehicles at (317) 232-2840 for assistance.

  10. Is the information on the SR21 form confidential?

    Yes, by law, the information provided on the SR21 form is confidential and cannot be used as evidence in any trial. This protection ensures that your personal information remains secure.

Misconceptions

Understanding the Indiana SR21 form is crucial for drivers involved in a collision. However, several misconceptions often arise. Here are nine common misunderstandings:

  • The SR21 form is optional. Many people believe that submitting this form is optional. In reality, if a collision results in injury, death, or property damage of $1,000 or more, it is required by law to submit the SR21 form within ten days.
  • Only the driver needs to fill it out. Some think that only the driver involved in the crash needs to complete the form. However, all drivers involved in the collision must provide their information, including their insurance details.
  • Insurance information is not necessary. There's a misconception that you can submit the form without insurance details. If you were insured at the time of the collision, you must have your insurance agent's signature on the form to verify coverage.
  • The report is public information. Many believe that the SR21 form is public and can be accessed by anyone. In fact, the report is confidential and cannot be used as evidence in court.
  • Only police officers can submit the form. While police officers often help with the report, any driver involved in the crash can fill out and submit the SR21 form, especially if the officer is unable to do so.
  • You can submit the form to any county office. Some think they can send the form to any local office. The SR21 must be sent specifically to the Bureau of Motor Vehicles, not the county where the crash occurred.
  • Handwriting is acceptable. It's a common belief that handwriting is fine for filling out the form. However, the instructions specify that all information should be printed in capital letters using black or blue ink for clarity.
  • Delays in reporting are acceptable. Some drivers think they can take their time submitting the form. Delaying beyond the ten-day requirement can lead to penalties, including suspension of your driver's license.
  • The form is only for serious accidents. Many people assume that the SR21 is only necessary for severe accidents. In truth, any collision resulting in property damage of $1,000 or more mandates the filing of this form.

Being aware of these misconceptions can help ensure that you handle the aftermath of a collision correctly and avoid potential legal issues.