Fill and Sign the Motor Vehicle or Car Accident Report Form

1. DRIVER'S NAME (Last, first, middle) MOTOR VEHICLE REPORT 4a. DEPARTMENT PERMANENT OFFICE ADDRESS SECTION I - DATA 5. TAG OR IDENTIFICATION NUMBER 2. DRIVER'S LICENSE NO./STATE/LIMITATIONS 6. EST. REPAIR COST 7. YEAR OF VEHICLE 8. MAKE I $ 3. DATE OF ACCIDENT 10. SEAT BELTS USED In YES n No 4b. WORK TELEPHONE NUMBER ( 1 11. DESCRIBE VEHICLE DAMAGE 1 SECTION II - OTHER VEHICLE DATA (Use Section Vlll if additional space is needed.) 15a. DRIVER'S HOME ADDRESS 12. DRIVER'S NAME (Last, first, middle) 14a. DRIVER'S WORK ADDRESS 15b. HOME TELEPHONE NUMBER ~( 1 13. DRIVER'S LICENSE NUMBER/STATE/LIMITATlONS 14b. WORK TELEPHONE NUMBER ( 1 16. DESCRIBE VEHICLE DAMAGE 17. ESTIMATED REPAIR COST I $ 18. YEAR OF VEHICLE 19. MAKE OF VEHICLE 20. MODEL OF VEHICLE 21. TAG NUMBER AND STATE 22a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS 22b. POLICY NUMBER ;2c. TiLEPHONE NUMBER 24b. TELEPHONE NUMBER ~( 1 23. VEHICLE IS [7 CO-OWNED [7 RENTAL [7 LEASED [7 PRIVATELY OWNED 25. OWNER'S ADDRESS(ES1 24a. OWNER'S NAME(S) (Last, first, middle) SECTION Ill - KILLED OR INJURED (Use Section Vlllif additionalspace is needed.) 36. NAME (Last, first, middle) I 37. SEX 38. DATE OF BIRTH 26. NAME (Last, first, middle) A 39. ADDRESS 27. SEX a. NAME OF STREET OR HIGHWAY 28. DATE OF BIRTH 30. MARK "X" IN TWO APPROPRIATE BOXES B 31. IN WHICH VEHICLE [7 [7 OTHER (2) [7 KILLED [7 INJURED [7 DRIVER [7 PASSENGER [7 HELPER [7 PEDESTRIAN 34. TRANSPORTED BY b. DIRECTION OF PEDESTRIAN (SW corner to NE corner, etc.) 32. LOCATION IN VEHICLE 35. TRANSPORTED TO 40. MARK "X" IN TWO APPROPRIATE BOXES FROM 46. Pedes- tr~an 33. FIRST AID GIVEN BY 41. IN WHICH VEHICLE [7 [7 OTHER (2) [7 KILLED [7 INJURED TO c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (Crossing intersection with signal, against signal, diagonally; in roadway pla ylng, walk~ng, hltchhlk~ng, etc.) [7 DRIVER [7 PASSENGER [7 HELPER [7 PEDESTRIAN 44. TRANSPORTED BY 42. LOCATION IN VEHICLE 45. TRANSPORTED TO 43. FIRST AID GIVEN BY OPERATOR OPERATOR INSTRUCTIONS: Sections I thru VIII are to be filled out by the vehicle operator. Section X, Items 72 thru 82c are to be filled out by the operator's supervisor, if applicable. (Section IX has been intentionally deleted). Sections XI thru XIII are to be filled out by an accident investigator. 49. TlME OF ACCIDENT PM SECTION IV - ACCIDENT TlME AND LOCATION (Use Section Vlll if additionalspace is needed.) 50, INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED Use one of these outlines to sketch the scene. Write in street or highway names or numbers. 47. DATE OF ACCIDENT a. Number vehicle as 7, other vehicle as 2, additional vehicle as 3 and show direction of travel with arrow. Example: - 1 a - 48. PLACE OF ACCIDENT Istree! address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection: Kind of locality (industrial, busmess, res~dent~al, open country, etc.); Road description). b. Use solid line to show path before accident 12) 1' and broken line after the accident - - - - - - - - - c. Show pedestrian d. Show railroad by , , , , , , , , , , , , e. Place arrow in this circle to indicate NORTH 0 51 .POINT OF IMPACT (Check one for each veh~clel I FED 2 I AREA 1 1 a. FRONT 1 1 1 b. R. FRONT c. L. FRONT 52. DESCRIBE WHAT HAPPENED (Refer to vehicles "2': "3': etc. Please include information on posted speed limit, approximate speed of the vehicles, road conditions, weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signal, etc.) condition of light (daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making U-turn, passing, stopped in traffic, etc.). 56. BUSINESS ADDRESS A+ SECTION V - WITNESSIPASSENGER (Witness must fill out SF 94, Statement of Witness) (Continue in Section V1ll.J 57. HOME ADDRESS + 53. NAME (Last, first, middle) 1 58, NAME (Last, first, middle) 61. BUSINESS ADDRESS BF 54. WORK TELEPHONE NUMBER TELEPHONE NUMBER TELEPHONE NUMBER 55. HOME TELEPHONE NUMBER 62. HOME ADDRESS SECTION VI - PROPERTY DAMAGE (Use Section Vlll if additional space is needed.) 63a. NAME OF OWNER TELEPHONE NUMBER TELEPHONE NUMBER 63d. BUSINESS ADDRESS 63e. HOME ADDRESS 64a. NAME OF INSURANCE COMPANY 74b TYONE NUMBER 64c POLICY NUMBER 69. PRECINCT OR HEADQUARTERS 65. ITEM DAMAGED 66. LOCATION OF DAMAGED ITEM 70a. PERSON CHARGED WITH ACCIDENT 67. ESTIMATED COST $ 70b. VIOLATION(S) 68c. TELEPHONE NUMBER SECTION VII - POLICE INFORMATION 68a. NAME OF POLICE OFFICER 68b. BADGE NUMBER 1 operator's SECTION Vlll - EXTRA DETAILS SPACE FOR DETAILEDANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND PAPER. I certifv that the information on this form (Sections / thru VlllI is correct to the best of mv knowledae and belief. 72. ORIGIN 73. DESTINATION 71 a. NAME AND TITLE OF DRIVER 74. EXACT PURPOSE OF TRlP 71 b. DRIVER'S SIGNATURE AND DATE 75. TRlP BEGAN I DATE SECTION X - DETAILS OF TRlP DURING WHICH ACCIDENT OCCURRED TlME (Circle one) 76. ACCIDENT p.m. OCCURRED I DATE TlME (Circle one) a.m. p.m. 77. AUTHORITY FOR THE TRlP WAS GIVEN TO THE OPERATOR [7 ORALLY [7 IN WRITING (Explain) 78. WAS THERE ANY DEVIATION FROM DIRECT ROUTE YES (Explain) 79. WAS THE TRlP MADE WITHIN ESTABLISHED WORKING HOURS [7 YES [7 NO (Explain) 80. DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHER THAN THAT FOR WHICH THE TRlP WAS AUTHORIZED. YES (Explain) 81 .COMPLETED BY DRIVER'S SUPERVISOR a. DID THIS ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY [7 YES 82a. NAME AND TITLE OF SUPERVISOR b. COMMENTS 82b. SUPERVISOR'S SIGNATURE AND DATE 82c. TELEPHONE NUMBER ( 1 SECTION XI - ACCIDENT INVESTIGATION DATA 83. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION. [7 YES [7 NO (If "Yes", explain below.) 84. PERSONS INTERVIEWED 1 DATE NAME DATE 85. ADDITIONAL COMMENTS (Indicate section and item number for each comment.) SECTION XI1 - ATTACHMENTS LIST ALL ATTACHMENTS TO THIS REPORT SECTION Xlll - COMMENTSIAPPROVALS 86. REVIEWING OFFICIAL'S COMMENTS b. NAME (First, middle, last) b. NAME (First, middle, last) 87. ACCIDENT INVESTIGATOR c. TITLE 1 c. TITLE 88. ACCIDENT REVIEWING OFFICIAL d. OFFICE 1 d. OFFICE a. SIGNATURE AND DATE I a. SIGNATURE AND DATE e. OFFICE TELEPHONE NUMBER ( 1 e. OFFICE TELEPHONE NUMBER ( 1