MAIL TO:
DEPARTMENT OF PUBLIC SAFETY
SAFETY RESPONSIBILITY UNIT
PO BOX 1471
MONTGOMERY AL 36102-1471
Information and Instructions: Completion of this form is required ONLY if a motor vehicle accident occurring
in Alabama, caused death, personal injury, or property damage to any one owner in excess of $500 by an
uninsured motorist. You can only file this form if you have not been compensated for your injuries or losses.
DPS ACCIDENT CASE NO: __________________________________________________
DATE OF ACC: ____________________________________________________________
DRIVER’S NAME: __________________________________________________________
DRIVER’S LICENSE STATE: _________________________________________________
DRIVER’S LICENSE NUMBER: _______________________________________________
NAME AND ADDRESS OF PERSON MAKING CLAIM:
NAME: ___________________________________________________________________
ADDRESS: ________________________________________________________________
CITY: ________________________________STATE:____________ZIP:______________
PROPERTY DAMAGE CLAIM
I,________________________________, CERTIFY THAT DAMAGES TO MY VEHICLE AND/OR
PROPERTY AMOUNTED TO $________________, AS A RESULT OF THIS MOTOR VEHICLE
ACCIDENT. I BELIEVE MYSELF ENTITLED TO RECOVERY OF THE ABOVE AMOUNT FROM
________________ DRIVER AND FROM __________________________, OWNER OF THE OTHER
MOTOR VEHICLE INVOLVED IN THIS ACCIDENT, AND I HAVE NOT RELEASED SAID
PARTY(IES).
SIGNATURE OF OWNER: ______________________________________, DATE: _______________
(Must have title of person signing for company)
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INJURY CLAIM
I, _________________________________, CERTIFY THAT AS THE RESULT OF THIS MOTOR
VEHICLE ACCIDENT MY MEDICIAL EXPENSES ARE $_____________. I BELIEVE MYSELF
ENTITLED TO RECOVERY OF THE ABOVE AMOUNT FROM
_______________________________,DRIVER AND FROM ________________________,
OWNER OF THE OTHER MOTOR VEHICLE INVOLVED IN THIS ACCIDENT, AND I HAVE
NOT RELEASE SAID PARTY(IES).
SIGNATURE OF INJURED PARTY______________________________________, DATE: __________
(If Minor, signature of legal guardian)
SR-31
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