South Carolina Department of Motor Vehicles

For office use only

FR- 309
FR-309& FR- 21
__________________________ TRAFFIC COLLISION REPORT (Est. 7/05)
Est. 6/05
Sheet ______
_____ ofof_____
______sheet(s)
sheet(s) Not Investigated by Law Enforcement
According to South Carolina Law 56-5-1270, the driver or owner of a vehicle which is in any manner involved in an accident that is not investigated by law
According tothat
enforcement South Carolina
results Law
in total 56-5-1270,
property the driver
damages of oneorthousand
owner ofdollars
a vehicle which
or more orisinindeath
any manner involved
of bodily in an complete
injury, shall accident that
and is notthis
send investigated by law
form to South
enforcement
Carolina that results
Department in total
of Motor propertyFinancial
Vehicles, damagesResponsibility,
of one thousandP.O.
dollars
Box or moreBlythewood,
1498, or in death orSCbodily injury, shall
29016-0040 withincomplete
15 days and send
of the this form to South
collision.
Carolina Department of Motor Vehicles, Financial Responsibility, P.O. Box 1498, Blythewood, SC 29016-0040 within 15 days of the collision.

Date of collision Day of Week Time am County collision occurred

am ON
ON what street did it occur:
pm
pm

AT
AT what intersection did it occur, if applicable (street name): IN
IN what city or town did it occur:

Driver’s Full Name Street City State Zip Code

Circle Point of
Areas Damaged
1
Your Vehicle

Date of Birth Sex Race Driver’s License Number State Home Phone Work Phone
8 2
front

Make VIN Body Year Tag number Stat e Legally Parked ? (circle one) Yes / No
7 9 3

Owner’s Name Street City State Zip Code

6 4
5

Type of Vehicle (circle one): 01- Auto 03- Sta. Wagon 05- TR. Tractor 07- Farm 09- School Bus 11- Motorcycle Approximate Cost to
0 2- Bicycle 04- Panel-Pickup 06- Other Truck 08- Comm. Bus 10- Other Bus 12- Other: (Description)____________________________________ Repair: $___________

Other Driver’s or Pedestrian’s Full Name Street City State Zip Code
Circle Point of
Areas Damaged
Other Vehicle or Pedestrian

1
Date of Birth Sex Race Driver’s License Number State Home Phone Work Phone 8 2
front

Make VIN Body Year Tag number State Legally Parked ? (circle one) Yes / No 7 9 3

Owner’s Name Street City State Zip Code

6 4
5

Type of Vehicle (circle one): 01- Auto 03- Sta. Wagon 05- TR. Tractor 07- Farm 09- School Bus 11- Motorcycle Approximate Cost to
02- Bicycle 04- Panel-Pickup 06- Other Truck 08- Comm. Bus 10- Other Bus 12- Other: (Description)____________________________________ Repair: $___________

Damage to property other than vehicle (for example: fence, guardrail, mailbox, building, etc.)

Name of owner Street City State Zip Code

FR-309A
FR-21 COMPLETE REVERSE SIDE ALSO
Check here if a Form SR-23, Fleet policy of 25 or more vehicles is on file with the Department covering your vehicle.
Check here if a certificate of self-insurance has been issued by the department covering your vehicle and indicate the certificate number ______________
Check here if 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 below portion)
TO THE VEHICLE OWNER:
You
Youarearehereby
hereby required to return
required this this
to return formform
to thetoDepartment of Motor
the Department of Vehicles, FinancialFinancial
Motor Vehicles, Responsibility, P.O. Box 1498
Responsibility, P.O.Blythewood, SC 29016 withSC
Box 1498 Blythewood, the29016-0040
below portion
completed by an authorized
with the below agent or representative
portion completed of youragent
by an authorized insurance company showing
or representative that on
of your the date company
insurance and time stated abovethat
showing when
on the
themotor vehicle
date and timewas beingabove when
stated
operated, that it was an insured motor vehicle. If the Department within 15 days from the date accident does not receive this form, the owner’s registration and/or driving
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
privileges in this state could be suspended.
the accident, the owner’s registration and/or driving privileges in this state could be suspended.

TO BE COMPLETED BY INSURANCE AGENCY, BROKER, OR OTHER INSURANCE COMPANY REPRESENTATIVE

I hereby affirm that to the best of my knowledge the policy described below was in effect covering the vehicle listed on the date and time as mentioned.
(Failure to complete all information below will result in refusal of this form)
REPRESENTATIVE USE ONLY
REPRESENTATIVE USE ONLY
FOR INSURANCE COMPANY

FOR INSURANCE COMPANY

________________________________________________________________ ___________________________________________
Name of Insurance Company Policy Number

FROM: ____________________________ TO: ____________________________________ ___________________________________________

Policy Holder
The information as contained h erin is based solely upon my knowledge and belief as a representative of the above insurance company and no warranty of
liability is imputed to the above mentioned insurance company as I have listed herein.

____________________________________________________________________________________________ _________________________
Signature of Authorized Representative Title Phone Number NAIC Code Number
*(If insurance agent or broker indicate corresponding company code number assigned by the South Carolina Department of Insurance, indicate whether agent, broker, etc.)
Return this form to: S.C. Department of Motor Vehicles, Form FR-309, Financial Responsibility, Box 1498, Blythewood, SC 29016-0040
Return this form to: S.C. Department of Motor Vehicles, Form FR-309/FR -21, Financial Responsibility, Box 1498, Blythewood, SC 29016-0040
 SEATING RESTRAINT/SAFETY DEVICE INJURY
USE 1 2 3 00 – Not Used 0 – No Injury
CODES

APPROPRIATE M -Motorcycle 11 – Shoulder Belt Only 1 – Possible Injury

4 5 6
CODES IN B- Bicycle 12 – Lap Belt Only 2 – Injury/non-life threatening
BLOCKS O – Other 13 – Shoulder & Lap Belt 3 – Injury/life threatening
7 8 9
PROVIDED U - Unknown 21 – Child Safety Seat 4 – Death
P - Pedestrian 88 - Other

AGE SEX VEHICLE SEATING SAFETY INJURY

NUMBER BELTS

Name

Taken To: Taken By:

Name

Taken To: Taken By:

VICTIMS

Name

Taken To: Taken By:

Name

Taken To: Taken By:

Name

Taken To: Taken By:

Name Home Number Work Number Cell Number

WITNESSES

Name Home Number Work Number Cell Number

Name Home Number Work Number Cell Number

Please describe how the collision happened. Include factors that may have contributed to the collision such as road conditions, weather conditions, terrain, etc.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
NARRATIVE

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________

THE PERSON MAKING THIS REPORT MUST SIGN HERE

X___________________________________________________________________________________________________________________________________________
Signature Address Date

Mail this report to: S.C. Department of Motor Vehicles, FR 309/FR -21, Financial Responsibility, Box 1498, Blythewood, SC 29016-0040