FR 200 (07/01/2020)
SEX
VOLUNTARY REPORT OF A CRASH
Purpose: Use this form to voluntarily submit a report on a vehicle(s) crash.
Instruction: Print in ink or type. Mail the completed form to Insurance Verification Division at the above address. Keep
a copy of this form for your records.
SECTION A: CRASH INFORMATION
CRASH DATE (mm/dd/yyyy)
WAS THERE AN INJURY?
YES NO
WAS THERE A DEATH?
YES NO
WAS THERE DAMAGE TO VEHICLE?
YES NO
CRASH LOCATION (city/county) STATE
FEMALEMALE NON-BINARY
DRIVER FULL LEGAL NAME
CITY STATE ZIPCODEADDRESS
BIRTH DATE (mm/dd/yyyy)
SEX
DRIVER LICENSE NUMBER STATE
SECTION B: VEHICLE AND CLAIMANT INFORMATION (person filing report)
FEMALEMALE NON-BINARY
OWNER FULL LEGAL NAME
CITY STATE ZIPCODEADDRESS
BIRTH DATE (mm/dd/yyyy)
SEX
DRIVER LICENSE NUMBER STATE
VEHICLE MAKE VEHICLE MODEL STATELICENSE PLATE NUMBERVEHICLE YEAR
ROUTE NUMBER/STREET NAME NEAR INTERSECTION
FEMALEMALE NON-BINARY
DRIVER/PEDESTRIAN FULL LEGAL NAME
CITY STATE ZIPCODEADDRESS
BIRTH DATE (mm/dd/yyyy) DRIVER LICENSE NUMBER STATE
SECTION C: OTHER VEHICLE OR PEDESTRIAN INFORMATION
FEMALEMALE NON-BINARY
OWNER FULL LEGAL NAME
CITY STATE ZIPCODEADDRESS
BIRTH DATE (mm/dd/yyyy)
SEX
DRIVER LICENSE NUMBER STATE
VEHICLE MAKE VEHICLE MODEL STATELICENSE PLATE NUMBERVEHICLE YEAR
SECTION D: REPORTING REASON (check one)
The reason this report is being filed with the Department of Motor Vehicles:
I believe the other vehicle is uninsured.
Other vehicle owner unknown (pursuant to § 38.2-2206(D))
SECTION E: CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to
DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this
certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or
representation on this form is a criminal violation.
DATE (mm/dd/yyyy)
SIGNATURE
