Free Request for Taxpayer - Indiana

INDIANA OPERATOR'S PROOF OF INSURANCE/CRASH REPORT
State Form 52441 (R / 2-06) / SR21 Collision Date
MONTH DAY YEAR

Clear Form
AM PM

Day of Week

Actual Local Time

# of Vehicles

Reporting Officer Name

Badge #

County where crash occurred Road Collision Occurred On:

Nearest City/Town

Was Officer Report Reporting Police Agency Name Taken? Nearest Intersecting Road: Direction and distance to nearest intersection:

Send form to Bureau of Motor Vehicles. Do not send to Indiana State Police.

Local ID

Insured
Print Driver's Name (Last, First, MI) Address (Number, Street) Driver's License Number

Other Drivers Involved Print Driver's Name (Last, First, MI) Driver's License Number Sex
DATE OF BIRTH Day Year

Month

City Sex
DATE OF BIRTH Day Year

State License Type

ZIP License State

Print Driver's Name (Last, First, MI) Driver's License Number Print Driver's Name (Last, First, MI) Sex
DATE OF BIRTH Day Year

Month

Month

Print Owner's Name & Address Veh. Yr. Make Model Lic. Yr. Lic. Plate # Date Signed Lic. State

Driver's License Number Signature

Sex

Month

DATE OF BIRTH Day Year

Name of Person Submitting This Report

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:

Important!
Send to:

Bureau of Motor Vehicles PFR/Crash Report Section 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.