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REPORT OF TRAFFIC CRASH

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SR-1 (Revised 09/2017) Page 1 of 2
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Rural Nevada (877) 368-7828
TDD (Hearing Impaired Only):
(775) 684-4904
Website: www.dmvnv.com
REPORT OF TRAFFIC CRASH
(NRS 484E.070, 484E.080)
INSTRUCTIONS:
Pursuant to NRS 484E.070, this SR-1 report needs to be completed within 10 days after a crash that occurred in the State of Nevada
and was NOT investigated at the scene by law enforcement. Please complete ALL sections. This report cannot be accepted or processed
unless ALL information has been completed for ALL DRIVERS AND VEHICLES that were involved in the crash.
THE FOLLOWING ATTACHMENTS MUST BE INCLUDED (this SR-1 report will be considered VOID if not attached):
(1) a copy of your insurance that was in effect on the date of the crash for the vehicle involved;
(2) an estimate of repairs or a statement of total loss if there was $750 or more in vehicle or property damage (of any one person);
and
(3) a doctor’s statement of injury for each person injured in your vehicle (if the crash resulted in bodily injury or death).
Once completed, please sign your name on the second page, attach all required documents, and mail the complete report to the DMV at
the above address. Only reports that have been properly completed for all drivers and vehicles, and include the required attachments, will
be accepted and processed. Any SR-1 report that is incomplete or does not meet the requirements of NRS 484E.070, as specified above,
will not be retained by the Department. Failure to submit this report after it has been requested by the Department of Motor Vehicles may
result in the suspension of your driving privilege for up to one year (per NRS 484E.080).
CRASH INFORMATION:
Date and time of crash:
Date
Day of Week
LOCATION WHERE THE CRASH OCCURRED:
Highway No. or Street Name
City
DRIVER AND VEHICLE INFORMATION:
If more than two vehicles were involved, please provide the additional driver and vehicle information on a separate
page. NOTE: Plate number only will NOT be accepted.
No. 1
Driver
1-
Pedestrian
2-
Parked Vehicle
3-
Pedal Cyclist
4-
Other
5-
No. 2
Driver
1-
Pedestrian
2-
Parked Vehicle
3-
Pedal Cyclist
4-
Other
5-
Name (Last, First, Middle)
Name (Last, First, Middle)
Street Address City State Zip
Street Address City State Zip
Driver License No. and State
Date of Birth (MM/DD/YYYY)
Driver License No. and State
Date of Birth (MM/DD/YYYY)
License Plate No. and State Year and Make
License Plate No. and State Year and Make
Body Type Vehicle ID No.
Body Type Vehicle ID No.
OWNER’S INFORMATION: If the driver and owner of the vehicle are the same, please print “Same as Above.”
No. 1
No. 2
Owner’s Name (Last, First, Middle)
Owner’s Name (Last, First, Middle)
Owner’s Street Address
City
State
Zip
Owner’s Street Address
City
State
Zip
Owner’s Driver License No. and State
Owner’s Date of Birth
Owner’s Driver License No. and State
Owner’s Date of Birth
SR-1 (Revised 09/2017) Page 2 of 2
INSURANCE INFORMATION:
A COPY OF YOUR INSURANCE CARD MUST BE ATTACHED TO THIS REPORT.
Please ensure to attach a copy of your insurance card that was in effect on the date of the crash for the vehicle
involved. This information is necessary to verify that the vehicle was insured at the time of the crash. If insurance was not in
effect on the date of the crash, your driving privilege and registration may be suspended under Chapter 485 of Nevada Revised
Statutes.
CRASH DESCRIPTION
PROPERTY DAMAGE (other than the vehicle):
If you answer “Yes” below, please explain in the space provided:
Yes
No
Was there damage to property other than the vehicle? If Yes, describe:
Property Owner’s Name:
Property Owner’s Address:
ESTIMATE OF REPAIRS:
AN ESTIMATE OF REPAIRS OR A STATEMENT OF TOTAL LOSS MUST BE ATTACHED if there was $750 or more in
vehicle or property damage (of any one person). Pursuant to NRS 484E.070, the estimate of repairs or statement of total loss
must be from an established repair garage, an insurance adjuster employed by an insurer licensed to do business in the State
of Nevada, an adjuster licensed pursuant to chapter 684A of NRS, or an appraiser licensed pursuant to Chapter 684B of NRS.
This SR-1 report will be considered VOID if not attached.
PERSONAL INJURY:
If an injury occurred, A DOCTOR’S STATEMENT OF INJURY FOR EACH INDIVIDUAL INJURED IN YOUR VEHICLE
MUST BE ATTACHED. VOID if not attached!
Driver
Passenger
Name
Age
Sex
Street Address
City
State
Zip Code
Relationship to Driver of Your Vehicle*
*Husband, wife, son, daughter, etc.
Nature and Extent of Injuries
SIGNATURE:
By completing this report, you are authorizing the Department of Motor Vehicles to release your name, mailing
address, and insurance information to the other parties involved in the traffic crash and/or to their insurer
(NRS 484E.070).
I hereby certify all statements made in this report are true. I agree and understand any person who completes this
report knowing or having reason to believe the information is false is guilty of a gross misdemeanor. (NRS 484E.080)
Signature
Date Signed
*** VOID IF NOT SIGNED ***
NOTE: Only reports that have been properly completed for all drivers and vehicles, and include the required
attachments, will be accepted and processed. Any SR-1 report that is incomplete or does not meet the
requirements of NRS 484E.070, as specified above, will not be retained by the Department.
Please write a brief description of the crash:
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REPORT OF TRAFFIC CRASH

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Completed 23 December 2020

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