SR‐21
Revised12/2018
A
LABAMA
L
AW
E
NFORCEMENT
A
GENCY
D
RIVER
L
ICENSE
D
IVISION
301
S
OUTH
R
IPLEY
S
TREET
/
P.O.
B
OX
1471
/
M
ONTGOMERY
,
AL
36102-1471
P
HONE
334.242.4200
/
WWW
.
ALEA
.
GOV
RETURN TO:
Alabama Law Enforcement Agency
Safety Responsibility Unit
P.O. Box 1471
Montgomery, AL 36102-1471
Phone: 334-242-4222
Proof of Liability Insurance
If there was a liability policy in effect on the date of accident to cover liability for damage or injury to
others, you may complete the information below and return to the Safety Responsibility Unit.
You must have the insurance company name and policy number on this form
CASE NUMBER: _____________________________________________________________________
Name of Liability Insurance Company: ____________________________________________________
Policy Number: _______________________________________________________________________
Policy Period from: _______________________________ To: _____________________________
Date of Accident: _______________________________ in or near ______________________, Alabama
Make of Vehicle: ______________________________________________________________________
Driver: _________________________________________ Address: _____________________________
Owner: _________________________________________ Address: _____________________________
Policy Holder: ___________________________________ Address: _____________________________
