The Indiana SR21 form is the official Operator’s Proof of Insurance and Crash Report required for drivers involved in accidents resulting in injury, death, or property damage exceeding $1,000. This form must be submitted to the Bureau of Motor Vehicles within ten days of the collision. Ensure accurate completion to avoid complications and potential penalties.
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The Indiana SR21 form is an important document used to report motor vehicle crashes in the state. It is often accompanied by several other forms and documents that serve specific purposes related to the incident. Below is a list of commonly used forms that may be necessary alongside the SR21.
Understanding these accompanying documents can help individuals navigate the aftermath of a vehicle collision more effectively. Each form plays a specific role in ensuring that all necessary information is documented and processed properly, aiding in claims and legal resolutions.
Neglecting to Provide All Required Information: It's crucial to fill in every section of the form. Missing details can delay processing and may lead to complications.
Using Incorrect Ink Color: The instructions specify that the form should be completed in black or blue ink. Using other colors can result in the form being rejected.
Failing to Sign the Form: Ensure that you or your insurance agent signs the report. A missing signature could imply that you were not insured at the time of the collision.
Inaccurate Driver Information: Double-check that all driver details, including names and license numbers, are correct. Errors can create confusion and hinder the processing of your report.
Not Reporting Within the Required Time Frame: The form must be submitted within 10 days of the collision. Delays can lead to penalties, including potential suspension of your license.
Ignoring the 'Other Drivers Involved' Section: Be sure to list all other drivers involved in the crash. Omitting this information can lead to incomplete records and potential legal issues.
Not Marking 'Unknown' for Uncertain Information: If you're unsure about an answer, it's better to mark it as "unknown" rather than leaving it blank. This shows you made an effort to provide accurate information.
Key Takeaways for Filling Out the Indiana SR21 Form
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Indiana Secretary of State Annual Report - The form is available through the State Board of Accounts’ website for easy access.
INDIANA OPERATOR’S PROOF OF INSURANCE/CRASH REPORT
STATE FORM 52441 (R / 2-06) / SR21
Collision Date
Day of Week
Actual Local Time
AM
# of Vehicles
Reporting Officer Name
Badge #
Send form to Bureau
MONTH
DAY
YEAR
PM
of Motor Vehicles.
Do not send to
County where crash occurred
Nearest City/Town
Was Officer Report
Reporting Police Agency Name
Indiana State Police.
Taken?
Road Collision Occurred On:
Nearest Intersecting Road:
Direction and distance to nearest intersection:
Local ID
Insured
Print Driver’s Name (Last, First, MI)
Driver’s License Number
Address (Number, Street)
City
State
ZIP
Sex
DATE OF BIRTH
License Type
License State
Month
Day
Year
Print Owner’s Name & Address
Veh. Yr.
Make
Model
Lic. Yr.
Lic. Plate #
Lic. State
Other Drivers Involved
Name of Person Submitting This Report
Date Signed
Signature
THIS SECTION MUST CONTAIN THE SIGNATURE OF YOUR INSURANCE AGENT, IF YOU HAD INSURANCE AT THE TIME OF THE COLLISION. The company signatory hereto gives notice that its policy issued to the above named insured is a motor vehicle liability policy approved by the Commissioner of Insurance of the State of Indiana and was in effect on the date of the above described collision. A signature by an insurance agent or authorized representative is verification that the above driver (Insured) was insured at the time of the collision. Omission of agent signature signifies the driver was NOT insured at the time of the collision.
Insurance Company
Agency Name
Phone #
Date of Certification
Insured’s Policy Number
Signature of Authorized Insurance Representative
Date
Instructions for Completing the Indiana Operator’s Crash Report
Collisions resulting in injury, death or damage of $1000 or more (as determined by the reporting officer) must be reported on this form within 10 days. PRINT ALL INFORMATION USING ALL CAPITAL LETTERS (except your signature). Complete in black or blue INK.
Answer all questions to the best of your knowledge. If you are unable to answer any question, mark “unknown” or “U”. If the answer does not apply, mark with a slash (\) through the box.
YOU ARE THE INSURED. LIST THE DRIVER INFORMATION FOR ALL OTHER DRIVERS INVOLVED IN THE COLLISION UNDER “OTHER DRIVERS INVOLVED”.
If you were insured at the time of the collision, you must have the signature of the insurance agent before mailing the report.
Please submit this report to:
Bureau of Motor Vehicles
Important! PFR/Crash Report Section
Send to: P.O. Box 7169
Indianapolis, IN 46207
BY LAW, YOUR REPORT IS CONFIDENTIAL AND CANNOT BE USED AS EVIDENCE IN ANY TRIAL IC 9-26-3-4
The driver of any motor vehicle involved in a crash that results in injury or death or total property damage of $1000 or more must make a report on this form within ten
(10)days. The failure or refusal of any person to report a crash as required is cause for the suspension or revocation of the operator’s or chauffeur’s license and vehicle registration of such person. Such failure or refusal is also a misdemeanor. If the driver is physically incapable of making the report, any occupant of the vehicle is required to do so. A witness may also be required to make a report. A supplementary report will be required whenever an original report is insufficient.
The purpose of this report is to obtain information necessary to the administration of the Safety Responsibility Law and to obtain data useful in crash prevention. Complete and clear answers to all the questions are necessary. An accurate original report will avoid the necessity for supplementary reports. If you have difficulty in filling in the report, consult your nearest police authority or Bureau of Motor Vehicles at (317) 232-2840.