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AA-600 (11-09) COMMONWEALTH OF PENNSYLVANIA Driver’s Accident Report FORWARD THIS REPORT WITHIN 5 DAYS TO THE PENNSYLVANIA DEPARTMENT OF TRANSPORTATION, BUREAU OF HIGHWAY SAFETY AND TRAFFIC ENGINEERING, P.O. Box 2047, HARRISBURG, PA 17105-2047 T I M E Pennsylvania Vehicle Code, Section 3747 states: All reports are confidential, not available as trial evidence Date of Accident (Month - Day - Year) County Day of Week SEVERITY : Was Towing Required? J YES J NO UNIT 2: J YES J NO Number of Vehicles Involved TO PROPERLY LOCATE ACCIDENTS, USE AS Hour (AM - PM) City - Borough - Township Number Injured Check if Hit-Run J Number Killed MY VEHICLE • NO 1 LOCATION UNIT 1: On: (Street Name or Highway Number) LANDMARKS; SR SEGMENT NUMBERS, MILEPOSTS; INTERSECTION OF TWO HIGH-WAYS; At Intersection With: If Not At Intersection : _______ Feet N S E W Of Station Marker - Intersection - Etc… CITY, BOROUGH, TOWNSHIP, OR COUNTY LINES. Operator’s Name (First, Middle, Last) Mr. Mrs. Miss Date of Birth Address (Street, City, State, Zip Code) Vehicle License Number and State Owner’s Name (First, Middle, Last) Mr. Mrs. Miss Operator’s License Number and State Year Address (Street, City, State, Zip Code) Make Model PA TITLE OR OUT-OF-STATE VIN USE THE FOLLOWING SECTION TO RECORD VEHICLE NUMBER 2, PEDESTRIAN, OR OTHER PROPERTY Date of Birth Address (Street, City, State, Zip Code) OTHER Operator’s Name (First, Middle, Last) Mr. Mrs. Miss Vehicle License Number and State Owner’s Name (First, Middle, Last) Mr. Mrs. Miss Operator’s License Number and State Year Make Address (Street, City, State, Zip Code) PA TITLE OR OUT-OF-STATE VIN Description of Damaged Property Check If State Owned Property Model J IF MORE VEHICLES/PEDESTRIANS/OCCUPANTS ARE INVOLVED USE ADDITIONAL REPORTS. PERSONS INVOLVED NAME AGE SEX VEH.NO. INJURY CLASS 0 - NO INJURY 1 - DEATH 2 - MAJOR INJURY 3 - MODERATE INJURY 4 - MINOR INJURY 9 - UNKNOWN POSITION 1 - DRIVER 2-6 - PASSENGER 7 - PEDESTRIAN 8 - OTHER 1 2 3 4 5 6 ACTIVE RESTRAINT 0 - NONE 1 - SHOULDER HARNESS ONLY 2 - SEAT BELT ONLY 3 - COMBINATION (HARNESS & BELT) 4 - CHILD RESTRAINT 7 - MOTORCYCLE HELMET 8 - OTHER 9 - UNKNOWN PASSIVE RESTRAINT 0 - NONE OR PEDESTRIAN 1 - AIRBAG (DEPLOYED) 2 - AIRBAG (NOT DEPLOYED) 3 - AUTOMATIC SEAT BELT 8 - OTHER 9 - UNKNOWN Insurance Information Company Insurance Information Company Unit 1 Policy No. Unit 2 Policy No. INJURY TYPE SEATING ACTIVE PASSIVE POSITION RESTRAINT RESTRAINT WEATHER: J J Rain 0 = None 1 = 1 o'clock 2 = 2 o'clock 3 = 3 o'clock 4 = 4 o'clock 5 = 5 o'clock 6 = 6 o'clock 7 = 7 o'clock 8 = 8 o'clock 9 = 9 o'clock J Snow J Clear J Foggy ROADWAY: Other J Wet J Snowy J Dry J Icy VEHICLE NUMBER 1: INITIAL IMPACT POINT _______ 3 INITIAL IMPACT POINT _______ LEGAL SPEED _______ MPH LEGAL SPEED _______ MPH ESTIMATED SPEED _______ MPH 9 ESTIMATED SPEED _______ MPH 6 1. Draw Diagram As Clearly As You Can. 2. Show Your Vehicle As Number 1. 3. Label All Streets, Highways, and Landmarks. 4. Draw An Arrow In Circle Below So It Points North. 5. Complete Narrative. Indicate North By Arrow GIVE A DETAILED DESCRIPTION OF THE ACCIDENT IMMEDIATELY PRIOR TO IMPACT, AT IMPACT, AND IMMEDIATELY AFTER IMPACT, REFER TO VEHICLES BY NUMBERS SIGNATURE DATE J YES Rain VEHICLE NUMBER 2: INSTRUCTIONS: POLICE INVESTIGATED: J 12 10 = 10 o'clock 11 = 11 o'clock 12 = 12 o'clock 13 = Top of Vehicle 14 = Vehicle Undercarriage 15 = Use when the initial impact was with a towed unit (such as utility trailer vehicle, horse van, etc…) 99 = Unknown J NO If Yes, Name of Police Department: AA-600 (11-09) COMMONWEALTH OF PENNSYLVANIA Driver’s Accident Report This Form is to be completed only in the event that the accident was not investigated by a policy agency. The Driver’s Accident Report Form is required to be completed by ALL drivers involved in motor vehicle traffic accidents occurring within the Commonwealth of Pennsylvania and involves: (1) injury to or death of any person; or (2) damage to any vehicle involved to the extent that it cannot be driven under its own power in its customary manner without further damage or hazard to the vehicle, other traffic elements, or the roadway, and therefore requires towing. Section 3747(a) of Title 75, Pennsylvania Consolidated Statutes of the Vehicle Code requires that if a police officer does not investigate an accident required to be investigated by section 3746 (relating to immediate notice of accident to police department), the driver of a vehicle which is in any manner involved in the accident shall, within five days of the accident, forward a written report of the accident to the department. A Form, supplied by the Department of Transportation, has been designed for this purpose. That Form is the attached AA-600, Commonwealth of Pennsylvania Driver’s Accident Report. The primary objective of this Form is to obtain information which can be used to develop accident prevention and reduction programs aimed at reducing accidents and accident losses. In order for these programs to succeed, every attempt must be made to obtain the information for all items listed on the Report Form. Compliance with the following instructions will help to assure that the Report is filled out completely and accurately. A copy of the completed Accident Report should be retained for your records. If copies are requested from the Department of Transportation, a fee of $5.00 per copy will be required to cover our processing costs. Please send completed Forms to the following address: Pennsylvania Department of Transportation Bureau of Highway Safety and Traffic Engineering P.O. Box 2047 Harrisburg, Pennsylvania 17105-2047 GENERAL INSTRUCTIONS FOR COMPLETING DRIVER’S ACCIDENT REPORT Use a ballpoint pen and print all required information. Fill in every block applicable. The Form is self-explanatory. However, the following guidelines should be utilized: 1. For the Accident Location - - - Be sure to indicate the name of the City, Borough, or Township where the accident occurred as well as the Street name or Highway Route Number. If the accident occurred at an intersection, identify the name of the Street or Highway Route Number of the intersecting Roadway. If the accident did not occur at an Intersection, please use the nearest Cross Street, Mile Posts, or Segment Markers. Segment Markers are signs erected along the roadside. Where possible, the signs are placed at physical features such as bridges, pipes, or intersections. Mile Posts are generally erected along the roadside of Interstates. Do not use House Numbers, Utility Poles, etc. as reference points. 2. For the Vehicles, Drivers and Pedestrians - - - Copy information about drivers and vehicles directly from the official Driver’s License, Vehicle Registration Card, and Proof of Financial Responsibility Card. 3. Persons Involved - - - Record the names and addresses of all occupants (including Drivers) in the vehicles involved and ALL INVOLVED PEDESTRIANS regardless of injury severity. Begin with the Driver of Unit 1, then list the other occupants of Unit 1, if any. Repeat the procedure with any other units. 4. Injury, Seating Position, Safety Restraints - - - If applicable, select the appropriate codes for all occupants and pedestrians for the type of injury incurred, seating positions of all occupants, and the type of safety device used. 5. Damage Area of Vehicle - - - Select the appropriate code for the Initial Impact Point for each vehicle involved. To indicate the impact area, use clock points as shown at the vehicle representation on the back of the report. 6. Speed Limit and Travel Speed - - - Enter the speed limit of the roadway at the accident site. If the speed limit is not posted, write NP. Enter your estimate of the travel speed of each vehicle immediately before the accident. 7. For the Accident Diagram - - - The diagram is a visual representation of the accident location and the events that occurred. Show the movement of the vehicles, identify the roadways and be sure to include the North Arrow displayed on the back of the Report Form. 8. For the Narrative - - -Describe the actions of all involved persons and vehicles before, during and after the collision. Be as factual as possible and use the same Unit Numbers as those on the front of the Report to identify the vehicles and pedestrians. Avoid such brief narratives as “Unit 1 hit Unit 2”. IF MORE THAN TWO (2) VEHICLES ARE INVOLVED, OR ADDITIONAL SPACE IS NEEDED FOR OCCUPANTS, PLEASE USE ANOTHER FORM TO CAPTURE THE REQUIRED INFORMATION. IN THESE CASES, STAPLE REPORTS TOGETHER BEFORE SUBMISSION.