Fill and Sign the Imm 1017b Form PDF

ALASKA MOTOR VEHICLE CRASH FORM 12-209 CRASH INFORMATION Total # Vehicles DMV # (One choice per field unless otherwise noted. Other* should be explained in narrative) Crash Date Time of Crash Name of Street or Highway am Crash Day pm Miles Feet 03 WED 05 FRI 07 SUN Crash occurred in (City / Borough) 04 THU 06 SAT OFFICIAL USE ONLY Name of Cross Street, Highway, Bridge, etc. 01 MON 02 TUE North of: East of: South of: West of: At intersection with: Location Control Reference Point Weather Lighting Roadway / Junction 01 Blowing dirt, snow 07 Sleet, hail (freezing rain) 01 Dark - lighted roadway 07 Not reported 01 Crossover 07 Roundabout 13 Other* 02 Clear 08 Severe crosswinds 02 Dark - not lighted 08 Unknown 02 Driveway 08 T - intersection 09 Snow 03 Not a junction 09 Y - intersection 03 Cloudy 03 Dark - unknown lighting 04 Fog/ smoke 10 Other* 04 Daylight 04 On ramp 10 Four way intersection 11 Not reported 05 Twilight 05 Off ramp 11 Five point or more 05 Ice fog 06 Rain 12 Unknown 06 Other* 06 Railway crossing 12 Unknown First Sequence of Events (what was the first thing you crashed into, or what was the first event that resulted in the crash. (CHECK ONLY ONE FOR EITHER COLLISION OR NON-COLLISION COLLISION NON-COLLISION 01 Aircraft 09 Ditch 17 Median barrier 25 Train 02 Animal 10 Embankment 18 Moose 26 Tree / shrub 03 Bicyclist 11 Fence 19 Parked vehicle 27 Utility pole 04 Bridge / overpass 12 Guard rail face 20 Pedestrian 28 Vehicle in transit 05 Bridge rail 13 Guard rail end 21 Sideswipe 29 Vehicle - rear end 14 Light support 22 Sign 30 Vehicle - head on 06 Crash cushion 07 Culvert 15 Machinery 23 Snowberm 31 Vehicle - angle 16 Mail box 24 Traffic signal pole 32 Other fixed object 08 Curb / wall Location of First Sequence of Events (where did the crash happen first?) 01 Bike lane 04 Outside of trafficway 07 Roadway 10 Unknown 02 Gore 05 Parking lot 08 Shared use paths 06 Roadside 09 Shoulder 03 Median 33 Cargo loss / shift 34 Crossed median / centerline 35 Downhill runaway 36 Equipment failure 37 Explosion / fire 38 Immersion 39 Jackknife Road Surface 01 Dry 02 Ice 03 Water 40 Overturn 41 Ran off road 42 Separation of units 43 Other* 44 Unknown 07 Wet 08 Other* 04 Sand, mud, oil 05 Slush 06 Snow Did police investigate this crash? Yes No YOUR DRIVER INFORMATION Your Name (Vehicle Driver's Last Name, First Name, Middle Name) Your Date of Birth Your Driver License State Your Driver License Number Your Mailing Address Your State Your City Your Zip Code Your Contact Telephone Your Driver License Country Your Residence Country YOUR VEHICLE INFORMATION Your Vehicle Owner's Name (Last, First, Middle Initial) No. of Occupants Your Vehicle Damage 01 None / minor 02 Functional 03 Disabling 04 Totaled 02 03 05 Unknown Your Vehicle Owner's Mailing Address 04 Your Vehicle Owner's City Vehicle Year 05 01 Vehicle Owner's Telephone Your Vehicle Owner's State Vehicle Make Vehicle Model Vehicle Owner's Zip Code License Plate # Vehicle License State Damage Estimate Your Vehicle's Direction of Travel 01 North 02 South 03 East 04 West Over $501 05 Unknown Your Vehicle Driver's Injury Status (vehicle passengers are listed on page 2) 08 07 01 Fatal 02 Incapacitating 06 CHECK ONLY ONE TO SHOW FIRST AREA OF IMPACT Roadway Circumstances (that may have contributed to the crash) 01 Debris 02 Inoperative traffic device 03 Missing traffic device 04 Obscured traffic device 05 Obstruction in roadway 06 Shoulder 05 School zone signs 06 Stop sign 07 Traffic control signal 08 Warning signs 05 None 06 Not reported 07 Unknown Your Vehicle Action 07 Road surface condition 08 Ruts, holes, bumps 09 School zone 10 Work zone 11 Worn, polished road surface 12 None 13 Other* 14 Unknown Traffic Control 01 Flashing signal 02 No traffic controls 03 Road construction signs 04 RR crossing device 03 Non-incapacitating 04 Possible 09 Officer / Flagman / Guard 10 Yield sign 11 Other* 12 Unknown 01 Avoiding objects in road 02 Backing 03 Changing lanes 04 Entering traffic lane 05 Leaving traffic lane 06 Making U-turn 07 Merging Vehicle Configuration 08 Out of control 09 Passing 10 Parked 11 Skidding 12 Slowing 01 Dog sled 02 Light truck (4 tires) 03 Motorhome 04 Motorcycle 05 Off highway vehicle 06 Passenger car 07 Pedalcycle 08 Pedestrian 15 Straight ahead 16 Turning right 17 Turning left 18 Other* 19 Unknown 13 Starting in traffic 14 Stopped 09 Other* 10 Unknown C R A S H D E S C R I P T I O N (Write a brief narrative describing the crash) Fairbanks Police Department Rev. 07/05 Crash Form 12-209 - Page 1 ALASKA MOTOR VEHICLE CRASH FORM 12-209 OTHER DRIVER'S INFORMATION Other Driver's Name (Last Name, First Name, Middle Name) Other Driver's Date of Birth Other Driver's License State Other Driver's License # Other Driver's Mailing Address Other Driver's State Other Driver's Mailing Address City Other Driver's Contact Telephone Other Driver's License Country Other Driver's Zip Code Other Driver's Residence Country OTHER DRIVER VEHICLE INFORMATION Other Vehicle Damage Other Vehicle Owner's Name (Last, First, Middle Initial) Other Vehicle No. of Occupants 01 None / minor 02 Functional 03 Disabling 04 Totaled 02 05 Unknown 03 Other Vehicle Owner's Telephone Other Vehicle Owner's Mailing Address 04 Other Vehicle Owner's City Vehicle Year 05 01 Other Vehicle Owner's State Vehicle Make Vehicle Model Other Vehicle Owner's Zip License Plate # Damage Estimate Other Vehicle's Direction of Travel 01 North 02 South Vehicle License State 03 East 04 West Over $501 05 Unknown Other Vehicle Driver's Injury Status (vehicle passengers are listed below) 08 07 03 Non-incapacitating 04 Possible 01 Fatal 02 Incapacitating 06 CHECK ONLY ONE TO SHOW FIRST AREA OF IMPACT Other Driver's Roadway Circumstances (that may have contributed to the crash) 01 Debris 02 Inoperative traffic device 03 Missing traffic device 04 Obscured traffic device 05 Obstruction in roadway 06 Shoulder INJURY SECTION 05 School zone signs 06 Stop sign 07 Traffic control signal 08 Warning signs 13 Other* 14 Unknown 09 Officer / Flagman / Guard 10 Yield sign 11 Other* 12 Unknown 01 Avoiding objects in road 02 Backing 03 Changing lanes 04 Entering traffic lane 05 Leaving traffic lane 06 Making U-turn 07 Merging Other Driver's Vehicle Configuration 01 Dog sled 02 Light truck (4 tires) 03 Motorhome 04 Motorcycle 08 Out of control 09 Passing 10 Parked 11 Skidding 12 Slowing 13 Starting in traffic 14 Stopped 05 Off highway vehicle 06 Passenger car 07 Pedalcycle 08 Pedestrian Injury Status 02 Incapacitating 03 Non-incapacitating 04 Possible 05 None 07 Unknown 02 Incapacitating 03 Non-incapacitating 04 Possible 05 None 02 Incapacitating 03 Non-incapacitating 04 Possible 05 None 04 Possible 05 None Crash Location Your Mailing Address Your Date of Birth Your City Vehicle Owner's Name (Last Name, First Name, Middle Initial) Vehicle make Vehicle model SIGNATURE Your Zip Code Owner's Date of Birth Owner's City Vehicle Owner's Mailing Address Your Driver's License Number Your Driver's License State Your State License plate # Owner's Zip Code Vehicle License State YES Address and Telephone Number of Insurance Agent Your Contact Telephone Owner's License Number Owner's State Did you have a current automobile liability policy in effect covering this accident? Insurance Company or Insurance Carrier Name INSURANCE INFORMATION Failure to complete the Certificate of Insurance could result in the suspension of your driver's license) CERTIFICATE OF INSURANCE Crash Date Vehicle year Vehicle License 07 Unknown Your Name (Driver's Last Name, First Name, Middle Initial) VEHICLE INFORMATION Telephone 07 Unknown 03 Non-incapacitating YOUR INSURANCE INFORMATION VEHICLE OWNER INFORMATION 09 Other* 10 Unknown 07 Unknown 02 Incapacitating DRIVER INFORMATION 15 Straight ahead 16 Turning right 17 Turning left 18 Other* 19 Unknown (Fill in the name of injured person, injury status, telephone number, and which vehicle they occupied when the crash occurred) Name CRASH INFORMATION 07 Unknown Other Driver's Vehicle Action 07 Road surface condition 08 Ruts, holes, bumps 09 School zone 10 Work zone 11 Worn, polished road surface 12 None Other Driver's Traffic Control (traffic control for the other driver may have been different from yours) 01 Flashing signal 02 No traffic controls 03 Road construction signs 04 RR crossing device 05 None 06 Not reported Owner' License State Owner's Contact Telephone Vehicle Identification Number (VIN) NO Insurance Policy Number Insurance Policy FROM Period: TO YOUR SIGNATURE Insurance Verification: If the motor vehicle liability insurance policy listed above was not in effect for the motor vehicle listed at the time of the crash indicated above, the insurance company is to complete the following and return this form to the Division of Motor Vehicles at the address listed on the bottom right corner on page 2 of this form. If indicated coverage was in effect at the time of the crash, no action is required. REASON FOR DENIAL: Policy expired before crash Driver is not covered on policy Policy effective after crash Policy number given is incorrect Lapse in policy Other: Authorized Representative Signature / Date MAIL THIS FORM TO: DMV Main Office P.O. Box 110221 Juneau, AK 99811-0221 (907) 465-4361 Crash Form 12-209 - Page 2