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2. COLLISION INFORMATION
4. Date and Time of Collision
   Date and Time of Collision

   Date and Time of Collision
5. Day of the Week
6. County Collision Occurred In
8. On what street did the collision occur?
10. At what intersection did it occur (if applicable)?
12. In what city or town did it occur?
16. Your Vehicle
18. Driver's Full Name
20. Street Address
22. City
23. State
24. Zip Code
26. Home Phone
27. Work Phone
29. Make
30. Body
31. Year
32. State
34. Legally Parked?

    1. Yes
    2. No
36. Is the owner the same as the driver?

    1. Yes
    2. No
38. Owner's Name
40. Street Address
42. City
43. State
44. Zip Code
46. Type of Vehicle

    1. 01-Auto
    2. 02-Bicycle
    3. 03-Sta. Wagon
    4. 04-Panel-Pickup

    1. 05-TR. Tractor
    2. 06-Other Truck
    3. 07-Farm
    4. 08-Comm. Bus

    1. 09-School Bus
    2. 10-Other Bus
    3. 11-Motorcycle
    4. 12-Other
48. If other, please specify.
50. Approximate Cost to Repair
54. Other Vehicle or Pedestrian
56. Other Driver's or Pedestrian's Full Name
58. Street Address
60. City
61. State
62. Zip Code
64. Home Phone
65. Work Phone
67. Make
68. Body
69. Year
70. State
72. Legally Parked?

    1. Yes
    2. No
74. Is the owner the same as the driver?

    1. Yes
    2. No
76. Owner's Name
78. Street Address
80. City
81. State
82. Zip Code
84. Type of Vehicle

    1. 01-Auto
    2. 02-Bicycle
    3. 03-Sta. Wagon
    4. 04-Panel-Pickup

    1. 05-TR Tractor
    2. 06-Other Truck
    3. 07-Farm
    4. 08-Comm. Bus

    1. 09-School Bus
    2. 10-Other Bus
    3. 11-Motorcycle
    4. 12-Other
86. If other, please specify.
88. Approximate Cost to Repair
92. OTHER PROPERTY DAMAGE
94. Damage to property other than vehicle
    (e.g. fence, guardrail, mailbox, building, etc.)
96. Name of Property Owner
98. Street Address
100. City
101. State
102. Zip Code
106. Applicable Considerations

     1. Form SR-23, Fleet policy of 25 or more vehicles is on file with the Department covering your vehicle
     2. Certificate of self insurance has been issued by the department covering your vehicle
     3. Liability insurance was not in effect for your vehicle to comply with South Carolina Statutory Requirements

     If any of the above are applicable, disregard the "To the Vehicle Owner" note.
108. If self-insurance had been issued, please indicate the certificate number.
110. TO THE VEHICLE OWNER:
     You are hereby required to return this form to the Department of Motor Vehicles, Financial Responsibility, P.O. Box 1498, Blythewood, SC 29016-0040 with the below portion completed by an authorized agent or representative of your insurance company showing that on the date and time stated above when the motor vehicle was being operated, that it was an insured motor vehicle. If the Department does not receive this form within 15 days from the date of the accident, the owner's registration and/or driving privileges in this site could be suspended.
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112. 1. Receive an email copy of this form.
113. Email address

     This field is not part of the form submission.

114. Submit

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