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Arkansas Motor Vehicle Accident Report (SR-1)
Safety Responsibility Section
501-682-7100
For reporting motor vehicle accidents which result in damage to the property of any one person in excess of $1000.00 or in bodily injury to or in the death of any one person.  Click here for additional information.

This report must be filed within thirty (30) days of accident. 

Please Enter Your Vehicle Information

Your Vehicle Driver Information 

Driver's Name:  

Driver's License No.:  
Driver's License State:  
Street Address:  
City:  
State:  
Zip Code:  
Mailing Address:  
City:  
State:  
Zip Code:  
Email Address:  
 

Your Vehicle Owner Information (Complete if different than driver)

Owner's Name:  

Street Address:  
City:  
State:  
Zip Code:  
Mailing Address:  
City:  
State:  
Zip Code:  
 

Your Vehicle Description and License Information 

Vehicle Make:  

Vehicle Year:  
Vehicle License No.:  
State:  
 

Accident Information

Accident Location (city/town):  

Roadway Name:  
Date of Accident:   (mm/dd/yyyy)
Time of Accident:  
 

Property Damage Information 

Cost of repairing vehicle  
or replacing if total loss:
  
$  (must be in dollar amount)
Cost of damage to  
other property:
  
$  (must be in dollar amount)
Property Description:  
Description of Accident:  

Please Enter the Other Vehicle Information

Other Vehicle Driver Information 

Driver's Name:  

Driver's License No.:  
Driver's License State:  
Street Address:  
City:  
State:  
Zip Code:  
Mailing Address:  
City:  
State:  
Zip Code:  
 

Other Vehicle Owner Information (Complete if different than driver)

Owner's Name:  

Street Address:  
City:  
State:  
Zip Code:  
Mailing Address:  
City:  
State:  
Zip Code:  
 

Other Vehicle Description and License Information 

Vehicle Make:  

Vehicle Year:  
Vehicle License No.:  
State:  
 

Other Vehicle Damage Information 

Cost of repairing or  
replacing if total loss:
  
$  (must be in dollar amount)
Cost of damage to  
other property:
  
$  (must be in dollar amount)
 

Fatalities or Injuries to Persons in Your Vehicle: 

Please list names or person(s) injured or killed in accident.  Indicate if they were injured or killed while riding in your vehicle.

Person 1 Name:  

Injured

Killed

Person 2 Name:  

Injured

Killed

Person 3 Name:  

Injured

Killed

Person 4 Name:  

Injured

Killed
 

Verification of Liability Insurance (SR-21)

To be filled out by authorized insurance agent only.

Date of Accident: 

SR Case Number: 
 

Vehicle Information

Description of Vehicle in Accident: 

Vehicle Year or Model: 

Vehicle Make: 

VIN: 
 

Owner Information

Owner's Name: 

Street Address: 
City: 
State:  
Zip Code: 
Mailing Address: 
City: 
State:  
Zip Code: 
 

Operator Information

Operator's Name: 

Street Address: 
City: 
State:  
Zip Code: 
Mailing Address: 
City: 
State:  
Zip Code: 
 

Insurance Information

Insurance Company Name: 

Street Address: 

City: 

State:  
Zip Code: 
Agent's Name: 
Agent's Phone Number: 
Agent's e-Mail Address: 
Was limited liability insurance in   place at the time of accident? 

Yes

No
Liability limits equal or higher  
to Arkansas requirements?
 

Yes

No
Coverage applies to: 

Owner

Operator
Policy Number: