Fillable Public Safety YOU MUST FILL IN ALL INFORMATION (City of Anniston, Alabama)

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Public Safety YOU MUST FILL IN ALL INFORMATION (City of Anniston, Alabama)

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U.S.A. forms for City of Anniston, Alabama

BROWSE CITY OF ANNISTON, ALABAMA (AL) FORMS

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(PLEASE PRINT OR TYPE)
Alabama Department of
Public Safety
Driver License Division
Safety Responsibility Unit
P. 0. Box 1471
Montgomery, AL 36102-1471
COMPLETION OF THIS FORM IS REQUIRED BY §32-7-1, CODE OF ALABAMA 1975. FAILURE TO FILE A REPORTABLE ACCIDENT ON THIS FORM
MAY RESULT IN SUSPENSION OF YOUR DRIVER LICENSE.
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 $250. The driver is legally required to file a report on this form with the Department of Public Safety within thirty (30) days after the accident regardless of who is at fault and
regardless of whether or not the vehicle involved was covered by liability insurance at the time of the accident. If a driver is physically incapable of making such report, the owner of the motor vehicle
involved in such accident, within thirty (30) days after learning of the accident, make such report. Use additional forms if necessary.
YOU MUST FILL IN ALL INFORMATION FOR PROCESSING
HOW MANY VEHICLES
WERE INVOLVED
DATE OF ACCIDENT
TIME:
A. M.
For Office Use Only
P. M.
Claims
Injuries
Subject
LOCATION OF ACCIDENT (CITY) (STREET/HWY)
COUNTY
CITY
ZIP CODE
STATE
ZIP CODE
CITYSTATE
STATE
DRIVER LICENSE NUMBERDRIVERS DATE OF BIRTH SEX
DRIVER'S DATE OF BIRTH
DRIVER LICENSE #
STATE
M
SEX
M
FF
OWNER OF VEHICLE/PROPERTY
IF SAME AS DRIVER,
MARK BOX
OWNER OF VEHICLE/PROPERTY
IF SAME AS DRIVER,
MARK BOX
ADDRESS OF OWNER: STREET NO.
ADDRESS OF OWNER: STREET NO.
STATE
ZIP CODE
CITY
ZIP CODE
STATECITY
YOUR VEHICLE
OTHER VEHICLE (Use additional form if more than two (2) vehicles)
STATE
MAKE TYPE
COMMERCIAL
VEHICLE
YEAR
YES
TYPE
COMMERCIAL
VEHICLE
YEAR MAKESTATE
NO
VIN
LICENSE PLATE NO.
VINLICENSE PLATE NO.
PROPERTY DAMAGE
DESCRIPTION OF PROPERTY DAMAGE (OTHER THAN VEHICLE, HOUSE/FENCE, UTILITY POLE/ETC)
INSURANCE INFORMATION ON BACK MUST BE COMPLETED AND SIGNED
SR-13
(Revised 1-98)
(COMPLETE REVERSE SIDE)
YES
NO
For Office Use Only
DOC No.
Case No.
YOUR INFORMATION (PLEASE PRINT OR TYPE)
OTHER PARTY'S INFORMATION (PLEASE PRINT OR TYPE)
YOU ARE THE:
PEDESTRIANDRIVER PROPERTY
OWNER
OTHER PARKED HIT & RUN
PROPERTY
OWNER
OTHER PARTY WAS
PEDESTRIANDRIVER
PARKED HIT & RUN
OTHER
DRIVER'S NAME (FIRST, MIDDLE, LAST) TELEPHONE NO. DRIVER'S NAME (FIRST, MIDDLE, LAST) TELEPHONE NO.
CURRENT ADDRESS: STREET NO.
CURRENT ADDRESS: STREET NO.
Reset Form
YOUR INSURANCE INFORMATION
NONE
INJURED PERSONS IN YOUR VEHICLE
DID INJURED DIE?
FULL NAME OF INJURED IN YOUR VEHICLE
Complete the following as required by the Safety Responsibility Law of Alabama §32-7-1, and
following sections. Mark only the appropriate box. All information will be verified.
NOYES
ADDRESS: STREET NO.
1. When accident occurred, the vehicle I was driving was covered by liability
insurance with
ZIPSTATE
CITY
(List name of insurance company, not Agency's name)
POLICY NO.
SEX
M
INJURED WAS (Please Circle)
DRIVER PASSENGER PEDESTRIAN OTHER
DATE OF BIRTH
POLICY PERIOD FROM
TO
F
POLICY HOLDER
DID INJURED DIE?
FULL NAME OF INJURED IN YOUR VEHICLE
2. When accident occurred, the vehicle I was driving was not covered by liability
insurance
ADDRESS: STREET NO.
3. Form SR-23 (Fleet Policy) is on file with Department of Public Safety.
4. Your vehicle is a qualified carrier with Alabama Public Service Commission.
5. Department of Public Safety Self-Insurance Certificate No.
STATE
ZIP
CITY
SEX
INJURED WAS (Please Circle) DRIVER PASSENGER
PEDESTRIAN OTHER
DATE OF BIRTH
DATESIGNATURE
INFORMATION AND INSTRUCTIONS: Complete this portion of the form if you believe that another party is responsible for your damages and you have not been compensated
for them. You must give vehicle and/or other damages in dollar amount.
VEHICLE AND/OR OTHER PROPERTY DAMAGE
(Full Name of Person Making Claim) certify that damages to my property
I,
(Amount of Damage) as a result of this motor vehicle accident. I believe I am entitled to recover the amount specified from
amounted to $
(Driver of Vehicle) and from
(Owner of Vehicle), and I have not released said party(ies).
(If owner is a company, give title of person signing claim.)
Signature of Property Owner
INJURIES (Please complete one section for each party injured)
(Full Name of Person Injured) certify that my medical expenses are
I,
(Amount of Injury) as a result of this motor vehicle accident. I believe I am entitled to recover the amount specified above from
$
(Driver of Vehicle) and from
(Owner of Vehicle), and I have not released said party(ies).
Date
Signature of Claimant/Legal Guardian of Minor
(Full Name of Person Injured) certify that my medical expenses are
I,
(Amount of Injury) as a result of this motor vehicle accident. I believe I am entitled to recover the amount specified above from
$
(Driver of Vehicle) and from
(Owner of Vehicle), and I have not released said party(ies).
Date
Signature of Claimant/Legal Guardian of Minor
FORM COMPLETION REVIEW
1. Review form to ensure all blanks have been filled in.
2. Use your full, legal name.
3. Describe all property damage (Example: bicycle, farm equipment, house, fence, etc.)
4. Sign and date this form in spaces provided.
5. Use additional forms, if necessary. Be sure to include all information requested.
6. For more information call 334-242-4222.
NOYES
M
F
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Public Safety YOU MUST FILL IN ALL INFORMATION (City of Anniston, Alabama)

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Completed 22 January 2021

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