TENNESSEE DEPARTMENT OF SAFETY
AND HOMELAND SECURITY
OWNER / DRIVER REPORT
IMPORTANT: COMPLETE FORM BELOW AND MAIL TO: TN DEPARTMENT OF SAFETY AND HOMELAND SECURITY P.O. BOX 945
NASHVILLE, TN 37202-0945
DATE OF CRASH: |
PLACE OF CRASH: |
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Month/Day/Year |
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VEHICLE MAKE: |
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VEHICLE YEAR: |
NAME OF OPERATOR: |
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ADDRESS: |
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DRIVER LICENSE NUMBER: |
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STATE: |
NAME OF OWNER: |
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DRIVER LICENSE NUMBER: |
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STATE: |
WERE THERE INJURIES OR DEATH INVOLVED IN THIS CRASH? WERE THERE DAMAGES TO YOUR VEHICLE?
IF YES, WERE THEY LESS THAN $1,500? |
OR GREATER THAN $1,500 |
WERE THERE DAMAGES TO STATE OR LOCAL PROPERTY?
IF YES, WERE THEY LESS THAN $400? |
OR GREATER THAN $400 |
VEHICLE TYPE:
DOB:
MiddleMonth/Day/Year
EXPIRATION DATE:
DOB:
MiddleMonth/Day/Year
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EXPIRATION DATE: |
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YES |
NO |
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YES |
NO |
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IF OVER $1,500, ENTER AMOUNT |
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YES |
NO |
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IF OVER $400, ENTER AMOUNT |
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IF AVAILABLE, LIST THE FOLLOWING INFORMATION ON THE OTHER DRIVER INVOLVED IN THIS CRASH:
Last NameFirst NameMiddle Initial Driver License Number
DID YOU HAVE LIABILITY INSURANCE COVERAGE FOR THIS CRASH? |
YES |
NO |
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IF YES, PROVIDE COMPLETE INFORMATION BELOW: |
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NAME OF INSURANCE COMPANY (NOT AGENCY): |
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POLICY NUMBER: |
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POLICY PERIOD: |
FROM: |
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TO: |
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NAME OF POLICYHOLDER: |
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NAME OF INSURANCE REPRESENTATIVE (AGENCY) WHO ISSUED POLICY: |
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ADDRESS: |
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NOTE: THE INSURANCE INFORMATION YOU PROVIDE WILL BE FORWARDED TO THE INSURANCE COMPANY FOR VERIFICATION. |
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Signature |
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Date |
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SF-0395 (Rev. 12/18) |
RDA 1348 |
TENNESSEE DEPARTMENT OF SAFETY AND HOMELAND SECURITY
OWNER / DRIVER REPORT
As set forth under the provisions of 55-12-104, T.C.A., you must file, or have filed in your behalf, a personal report with the Department of Safety and Homeland Security, if you were involved in an automobile crash as an owner or driver involving death or injury, or in which damage to property was in excess of one thousand five hundred dollars ($1,500) to any person involved OR if an accident results in damage to state or local government property in excess of four hundred dollars ($400). This report is required regardless of who was at fault and in addition to any report filed by an investigating officer.
Failure to file a personal crash report with the Tennessee Department of Safety and Homeland Security may result in the suspension of driver license and registrations or nonresident operating privileges of any person involved in a crash.
Your report must be submitted to the Department within twenty (20) days from the crash. You can satisfy this requirement by completing the reverse side of this from and mailing it to the Tennessee Department of Safety and Homeland Security, P.O. Box 945, Nashville, TN 37202. If you have any questions, please call
toll-free (866) 903-7357 or the Telecommunications Device for the Deaf (615) 532-2281.
Thank you for your cooperation.
TENNESSEE DEPARTMENT OF SAFETY AND HOMELAND SECURITY
SF-0395 (Rev. 12/18) |
RDA 1348 |