Fillable Printable Car Accident Report Form - Massachusetts
Fillable Printable Car Accident Report Form - Massachusetts
Car Accident Report Form - Massachusetts
Commonwealth of Massachusetts
Motor Vehicle Crash Operator Report
How To Complete This Form
Please carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegible reports will be returned to you.
Section A: Crash Location
n
Provide the city/town where the crash occurred,
the date and time of the crash, and the number of
vehicles involved.
n
Complete section A1 or A2.
n
Use official names of all locations, streets and
landmarks.
n
Use street name and route #, if applicable .
n
Be as precise as possible when describing the
location.
n
Provide enough information to locate the crash
to a specific point, not just a street or roadway.
Section B: Vehicle You Were Driving
n
Provide information on your license and the
vehicle you were driving.
n
Use the codes provided to indicate the cause of
the crash.
Section C: You and Your Passengers
n
Provide information on you and your passengers
at the time of the crash.
n
Use the codes provided to indicate occupant
information.
Section D: Other Vehicles Involved in the
Crash
n
Provide information on the other vehicle(s) and
operator(s) involved in the crash.
n
If more than one vehicle involved, please use
additional form completing Section D only.
Section E: Non-Motorist(s) Involved
n
Provide information on the non-motorist(s)
involved in the crash.
n
If more than one non-motorist involved, please
use additional form completing Section E only.
Section F: Crash Conditions
n
Use the codes provided to indicate the
conditions at the time of the crash.
Section G: Crash Diagram
n
Draw a diagram of how the crash occurred.
n
On the diagram, Vehicle 1 represents your
vehicle.
Section H: Witness Information
n
List all the people who saw the crash but were
not involved.
Section I: Property Damage Information
n
Indicate all non-vehicular property that was
damaged in the crash.
Section J: Description of What Happened
n
Describe the crash including events prior to the
crash for your vehicles and all other vehicles.
Section K: Signature
n
Please sign and print your name and indicate the
date you completed the form.
Where to send completed reports:
q Mail or deliver one copy to the local police
department or state police in the city or town
where the crash occurred.
q Mail one copy to your Insurance Company.
q Mail one copy to the RMV at the following
address:
Crash Records
Registry of Motor Vehicles
P.O. Box 55889
Boston, MA 02205-5889
Page 1
CRA-23
When Must a Crash Report be filed with the Registrar?
M.G.L. Chapter 90, Section 26 requires a person who was operating a motor vehicle involved in a crash in which (i) any person was killed or (ii)
injured or (iii) in which there was damage in excess of $1,000 to any one vehicle or other property, to complete and file a Crash Operator
Report with the Registrar within five (5) days after such crash (unless the person is physically incapable of doing so due to incapacity). The
person completing the report must also send a copy of the report to the police department having jurisdiction on the way where the crash
occurred. If the operator is incapacitated but is not the vehicle's owner, the owner is required to file the crash report within the five (5) days
based on his/her knowledge and information obtained about the crash. The Registrar may require the owner or operator to supplement the
report and he/she can revoke or suspend the license of any person violating any provision of this legal requirement. A police department is
required to accept a report filed by an owner or operator whose vehicle has been damaged in a crash in which another person unlawfully left
the scene even if damage to the vehicle does not exceed $1,000.
T21278_0312
Please Indicate the Sequence of Events as they occurred to YOUR Vehicle by writing the corresponding number (1-52, or 97, 99) in up to 4 boxes below.
What happened first? What happened 2
nd
(if applicable)? What happened 3
rd
(if applicable)? What happened 4
th
(if applicable)?
Collision with
1 Motor vehicle in traffic
2 Parked motor vehicle
3 Pedestrian
4 Cyclist
5 Animal- deer
6 Animal- other
7 Moped
8 Work zone maintenance equipment
9 Railway vehicle (train, engine)
10 Other movable object
11 Unknown movable object
20 Curb
21 Tree
22 Utility pole
City/Town Where Crash Occurred Date of Crash Time of Crash
____ : ____ __ AM __ PM
Section A: Crash Location
# Vehicles
Involved:
Section B: Vehicle You Were Driving
Number of occupants in vehicle (including yourself): _________ Was vehicle damage above $1000? __Yes __No
Full Name of Vehicle Owner (Last, First, Middle) Street Address City/Town State Zip
23 Light pole or other post/support
24 Guardrail
25 Median barrier
26 Ditch
27 Embankment/Sloping shoulder
28 Highway traffic signpost
29 Overhead sign support
30 Fence
31 Mailbox
32 Crash cushion/Impact attenuator
33 Bridge
34 Bridge overhead structure
35 Other fixed object (wall, building, tunnel)
36 Unknown fixed object
Non-Collision
40 Ran off road right
41 Ran off road left
42 Cross median/centerline
43 Overturn/rollover
44 Equipment failure (blown tire, brakes, etc)
45 Fire/explosion
46 Immersion
47 Jackknife
48 Cargo/equipment loss or shift
49 Separation of units
50 Downhill runaway
51 Other non-collision
52 Unknown non-collision
97 Other
99 Unknown
Was your Vehicle Towed From the Scene Due to Damage? __Yes __No
0 None
10 Undercarriage
11 Totaled
97 Other
99 Unknown
8 7 6
2 3 4
1 9 5
Driver’s License Number License State Age Sex
__ M __ F
Date of Birth
Insurance Company
Vehicle Registration #
Reg. Type Reg. State Vehicle Year Vehicle Make
Your Full Name (Last, First, Middle) Street Address City/Town State Zip
SECTION A2: Complete this Section if the crash did NOT occur at an
intersection:
Step 1: Please indicate the route, roadway and address where the crash occurred:
The crash occurred on Route #: _______ at Street or Address Number: ________________
on the Street/Roadway known as: ______________________________________________
Step 2: Please provide as much of the following specific location information as possible:
The crash occurred (estimate number of feet) _______________ feet
(indicate direction as N/S/E/W) _______________ of
a) Mile Marker number ___ ___ ___ ___
OR: b) Exit Number ________________
OR: c) Intersecting Street/Roadway __________ ___________________________
Route# Name of Roadway/Street
OR: d) Landmark _______________________________________________________
Please complete Section A1 or A2 below to indicate the location of the crash.
If you need additional space to describe the crash location, please use Section J on the last page of this form.
Page 2
SECTION A1: Complete this Section if the crash
occurred at an intersection of two or more streets:
Step 1: Please indicate the route or roadway where you
were travelling when the crash occurred:
____________ __________________________________
Route# Name of Roadway/Street
Step 2: What was the name (or names) of the intersecting
streets?
____________ __________________________________
Route# Name of Roadway/Street
____________ __________________________________
Route# Name of Roadway/Street
OR
Indicate your type of vehicle
1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other
2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknown
pick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle
3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doubles
What Was Your Vehicle Doing Prior to the Crash?
1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other
2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown
3 Turning right 6 Entering traffic lane 9 Overtaking/passing
Commercial Driver’s License Endorsements
H __ Hazardous N __ Tank vehicles P__Passenger
T __ Doubles/Triples X __ Tank and Hazardous transport
License Class
__ D __ A __B __C
__ M __ Unknown
Vehicle Travel Direction
__N __S __E __W
Vehicle Damaged Area
(circle up to three)
B. Safety System Used
0 None used
1 Shoulder and lap belt
2 Lap belt only
3 Shoulder belt only
4 Child safety seat
5 Helmet
99 Unknown
A. Seating Position
1 Front seat - left side (or motorcycle driver)
2 Front seat - middle
3 Front seat - right side
4 Second seat - left side (or motorcycle passenger)
5 Second seat - middle
6 Second seat - right side
7 Third row - left side (or motorcycle passenger)
8 Third row - middle
A B C D E F G H Name of
Medical Facility
Section C: You and Your Passengers
Date of
Birth/Age
Sex
M/F
Driver (See previous page)
Name of Passenger 1 (Last, First, Middle)
Name of Passenger 2 (Last, First, Middle)
Name of Passenger 3 (Last, First, Middle)
Address
City/Town State Zip
Address
City/Town State Zip
Address
City/Town State Zip
9 Third row - right side
10 Sleeper section of cab
11 Enclosed passenger area
12 Unenclosed passenger area
13 Trailing unit
14 Riding on vehicle exterior
97 Other
99 Unknown
Full Name of Vehicle Owner (Last, First, Middle)
Street Address City/Town State Zip
Vehicle Travel
Direction
__N __S
__E __W
Driver’s License Number
Insurance Company
Vehicle Registration #
Reg. Type Reg. State Vehicle Year Vehicle Make
License State AgeDate of Birth
Full Name of Vehicle Driver (Last, First, Middle)
Street Address City/Town State Zip
Section E: Non-Motorist(s) Involved in the Crash
Date of Birth/Age
Sex
__M __ F
Full Name of Non-Motorist (Last, First, Middle) Street Address City/Town State Zip
Please provide the full name, address, and DOB or Age for all passengers in your vehicle. Then write the corresponding code in each of the boxes for each occupant of the vehicle
(yourself and all passengers). A list of the possible codes is provided at the bottom of this section.
Indicate the type of non-motorist involved
1 Pedestrian 2 Cyclist 3 Skater 97 Other 99 Unknown
What was the non-motorist doing prior to the crash?
1 Entering or crossing location 6 Working on vehicle
2 Walking, running, or cycling 7 Standing
3 Working 97 Other
4 Pushing vehicle 99 Unknown
5 Approaching or leaving vehicle
Safety Equipment?
0 None used 9 Lighting
6 Helmet 10 Other
7 Protective pads (elbows, knees, etc.) 99 Unknown
8 Reflective clothing
If transported, please indicate Hospital/Medical Facility:
Number of occupants in the Vehicle: _____
Hit and Run? __Yes __No
Section D: Other Vehicle(s) Involved in the Crash
Page 3
__ M __ F
Moped? __Yes __No
Number of injured occupants: _____
Vehicle Damaged Area (circle up to three)
0 None
10 Undercarriage
11 Totaled
97 Other
99 Unknown
1 9 5
8 7 6
2 3 4
C. Air Bag Status
1 Deployed-front
2 Deployed-side
3 Deployed both
front and side
4 Not deployed
5 Not applicable
99 Unknown
D. Air Bag Switch
1 Switch in ON position
2 Switch in OFF position
3 ON-OFF switch not present
4 Unknown if switch is present
99 Unknown
E. Ejected From Vehicle?
0 Not ejected
1 Totally ejected
2 Partially ejected
3 Not applicable
99 Unknown
F. Trapped?
0 Not trapped
1 Freed by mechanical means
2 Freed by non-mechanical means
99 Unknown
G. Injured?
1 Fatal injury
Non-fatal injury:
2 Incapacitating 5 No injury
3 Non-incapacitating 99 Unknown
4 Possible
H. Transported for Medical Care?
1 Not transported 97 Other
2 EMS (emergency service) 99 Unknown
3 Police
Commercial Driver’s License Endorsements
H __ Hazardous N __ Tank vehicles P__Passenger
T __ Doubles/Triples X __ Tank and Hazardous transport
Indicate type of vehicle
1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other
2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknown
pick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle
3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doubles
What Was the Vehicle Doing Prior to the Crash?
1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other
2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown
3 Turning right 6 Entering traffic lane 9 Overtaking/passing
Sex
License Class
__ D __ A __ B __C
__ M __ Unknown
Where was the non-motorist prior to the crash?
1 Marked crosswalk at intersection 6 Median (but not on shoulder)
2 At intersection but no crosswalk 7 Island
3 Non-intersection crosswalk 8 Shoulder
4 In roadway 9 Sidewalk
5 Not in roadway 10 Shared-use path or trails
99 Unknown
Injured?
1 Fatal injury
Non-fatal injury:
2 Incapacitating 5 No injury
3 Non-incapacitating 99 Unknown
4 Possible
Transported for Medical Care?
1 Not transported 97 Other
2 EMS (emergency service) 99 Unknown
3 Police
Was Vehicle Damage
__Yes ___No
above $1000?
Section F: Crash Conditions
Section G: Crash Diagram
Please draw a diagram of the
roadway or streets where the crash
occurred, indicating the vehicles
involved and direction of travel
using the following symbols:
= Direction
= Vehicle 1 (Your Vehicle)
= Vehicle 2
O = Pedestrian/Non-motorist
= North
Select one of the following if
the crash did not occur on a
public way:
___ Off-street parking lot
___ Garage
___ Mall/shopping center
___ Other private way
Section H: Witness Information
Witness Name (Last, First, Middle) Address Phone
Section I: Property Damage Information (Other than Vehicles)
AddressOwner Name (Last, First, Middle) Phone Property and Damage Description
Section J: Description of What Happened
Section K: Signature
_______________________________________________
“Signed under Pains and Penalties of Perjury”
Page 4
1
2
Indicate
North by
Arrow
Print ________________________________________ Date ___________________________
Light Conditions
1 Daylight
2 Dawn
3 Dusk
4 Dark - lighted roadway
5 Dark - roadway not lighted
6 Dark - unknown roadway
lighting
97 Other
99 Unknown
Weather Conditions (up to two)
1 Clear
2 Cloudy
3 Rain
4 Snow
5 Sleet, hail, freezing rain
6 Fog, smog, smoke
7 Severe crosswinds
8 Blowing sand, snow
97 Other
99 Unknown
Traffic Control Device
1 No controls
2 Stop signs
3 Traffic control signal
4 Flashing traffic control signal
5 Yield signs
6 School zone signs
7 Warning signs
8 Railroad crossing device
99 Unknown
Was the traffic
control device
functioning at
the time of the
crash?
1 ___ Yes
2 ___ No
Road Surface
1 Dry
2 Wet
3 Snow
4 Ice
5 Sand, mud, dirt, oil, gravel
6 Water (standing, moving)
7 Slush
97 Other
99 Unknown
Roadway Intersection Type
1 Not at intersection
2 Four-way intersection
3 T-intersection
4 Y-intersection
5 On ramp
6 Off ramp
7 Traffic circle
8 Five-point or more
9 Driveway
10 Railway grade crossing
99 Unknown
Trafficway Description
1 Two-way, not divided
2 Two-way, divided, unprotected median
3 Two-way, divided, protected median
4 One-way, not divided
99 Unknown
School Bus
Related?
1 ___ Yes
2 ___ No
Work Zone
Related?
1 ___ Yes
2 ___ No
Manner of Collision
1 Single vehicle crash 6 Head on
2 Rear-end 7 Rear to rear
3 Angle 99 Unknown
4 Sideswipe, same direction
5 Sideswipe, opposite direction
