Fillable Printable Car Accident Report Form - Oregon
Fillable Printable Car Accident Report Form - Oregon
Car Accident Report Form - Oregon
OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT
DMV
STK# 300009
Oregon law requires these reports be filed within 72 hours of the accident. If you are not able to file within the 72 hours,
submit it as soon as possible. If you fail to report the accident to DMV, it may result in suspension of your driving
privileges. If the police department files a police report, you are still required to file your own Accident and Insurance
Report with DMV. If you are an out-of-state resident, you are still required to file your own Accident Report with DMV.
DMV does not determine fault in an accident, but does post the accident to the driving record of those drivers required to
report, unless the vehicle is parked.
If you have questions, please call the Accident Unit at (503) 945-5098.
Tear this sheet off your report, read and carefully follow the directions.
ONLY drivers involved in an accident resulting in any of the following MUST file an Accident & Insurance Report:
s Damage to your vehicle is over $1500
s Injury (No matter how minor)
s Death
735-32 (4-15)
s Damage to any one person’s property over $1500
s Any vehicle has damage over $1500 and any vehicle
is towed from the scene as a result of damages
PURSUANT TO OREGON INSURANCE LAW, AN INSURANCE COMPANY CAN NOT REQUIRE REPAIRS BE MADE
TO A MOTOR VEHICLE BY A PARTICULAR PERSON OR REPAIR SHOP.
RECEIPT —Attached is a PINK courtesy copy of your report. After you have completed both sides of the form, tear the
PINK copy off for your records. If you want a receipt, bring the form, with the PINK copy, to a DMV office and have your
copy validated. Without a receipt, you will have no proof of submitting a report.
YOUR COPY —Under Oregon law ORS 802.220 (5), DMV can not provide you a copy of your Oregon Traffic Accident
and Insurance Report. If you wish to have a complete copy of your report (front and back), you will need to make a copy
for your records.
SECTION 3
SECTION 4
SECTION 5
COMPLETING AND FILING REPORT
OTHER SIDE OF FORM — Complete the other side of the form. Information collected from both sides of this form is used
by DMV and other officials in making valuable transportation decisions about the roadway systems and driver safety.
OTHER VEHICLE (# 2) —Completion of this information will help DMV match all driver's accident reports more efficiently.
If additional vehicles were involved in the accident, complete attached Supplemental Report (Form 735-32B).
DESCRIPTION AND SIGNATURE — Describe what happened. It is important for you to sign and date the form.
DATE, LOCATION AND TIME — Clearly identify the date, location and time of the accident. The correct date, location
and time is critical to processing your report. If you are unsure of the county, contact any local law enforcement agency for
assistance.
Complete both sides of the form.
If additional vehicles were involved in the accident, complete the attached Supplemental Report (Form 735-32B), or on
a blank piece of paper, write all the information as requested in Section 4, the “Other Driver” Section.
DMV Headquarters will verify the insurance information submitted. Complete the insurance section or a suspension of
your driving privileges may occur.
PRINT OR TYPE ALL INFORMATION. (Use black or dark blue ink and press firmly.)
SECTION 1
INSTRUCTIONS
s
s
s
SECTION 2
MAIL
— Mail the
form to Accident Reporting Unit, DMV, 1905 Lana Ave NE, Salem OR 97314 or FAX to (503) 945-
5267, or deliver it to any DMV office.
YOURVEHICLE(#1)— DMVwillconsideryouraccidentuninsuredifyoudonotcompleteALLof thissection.Youmust
listtheinsurancecompanyname(notagent)andpolicynumberthatprovidedliabilitycoverageforyouroperationofthe
vehicleyouweredrivingatthetimeoftheaccident.Notethecoverageisforliabilityinsurance,notcollisionor
comprehensivecoverage.DMVwillverifythisinformationwiththeinsurancecompany.Iftheinsurancecompanydenies
the coverage, DMV will suspend your Oregon driving privileges.
AnswerallofthequestionsinSection3.DMVwillusetheinformationprovidedinthesequestionstocodetheaccident.It
isimportantforyoutounderstand“principalpurposeofdriving”and“paidtodrive.”TheseincludeONLYpersons
employedorbeingpaidforthepurposeofdriving,NOTdrivingtoreachadestinationtoperformaservice.Property
includes, but is not limited to, fixed or real property, landscaping, signs, parked vehicles, and animals.
COMMERCIALMOTORVEHICLEOPERATORS:Inadditiontothisreport,OregonAdministrativeRulerequiresthat
Form735-9229,MotorCarrierCrashReport,MUSTbefiledwithin30daysofacommercialmotorvehicleaccident
whenthereisaFATALITY,INJURY(requiringtreatmentawayfromthescene),orwhenavehicleisTOWEDfromthe
scenebecauseof disablingdamage.Form735-9229 (attachedon back)MUSTbesubmittedwithOregonTrafficAccident
and Insurance Report (Form 735-32) to DMV. Call (503) 986-3507 for questions regarding the Motor Carrier Crash Report.
“Totaled Vehicle” or “Totaled” as defined in Oregon law (ORS 801.527) means:
TOTALED VEHICLE NOTICE
FOLLOW THESE INSTRUCTIONS IF YOUR VEHICLE IS TOTALED
DEFINITIONS AND INSTRUCTIONS FOR TOTALED VEHICLES
IF YOUR ACCIDENT HAS RESULTED IN A “TOTALED” VEHICLE, YOU ARE REQUIRED BY LAW TO
FOLLOW APPROPRIATE INSTRUCTIONS IN THIS NOTICE.
DEFINITION OF “TOTALED” VEHICLE
If your vehicle is totaled, in addition to completing the accident report, follow the instruction that is applicable to
your case. Either:
1.SURRENDER the title to the insurer if the damage is covered by an insurer who declares the vehicle to be a
“total loss,” and the insurer takes possession of the vehicle; or
2.SURRENDER the title to DMV and apply for salvage title if the damage is covered by an insurer who declares
the vehicle to be a “total loss,” but you keep possession of the vehicle; or
3.SURRENDER the title to DMV and apply for salvage title if the damage was not covered by an insurer and the
estimated cost of repair is at least 80% of the retail market value of the vehicle before the damage; or
4.NOTIFY DMV that your vehicle has been totaled if, for some reason, you are unable to obtain the title for
surrender. You must provide DMV with a signed statement which includes:
•A description of the vehicle which includes the year model, make, plate number and vehicle identification
number.
•A statement indicating the vehicle has been totaled.
•A statement that you are unable to obtain the title and why.
DO NOT SUBMIT THE TITLE WITH THE ACCIDENT REPORT. You can obtain the Application for Salvage Title
(Form 735-229) from any DMV office, by calling (503) 945-5000, or on-line at www.oregondmv.com. Application
instructions and fee information are on the back of the form 735-229. If you have questions about salvage titles,
call (503) 945-5122.
NOTE: It is a Class A misdemeanor with a penalty of imprisonment and/or fine if you fail to comply with the above
requirements. (ORS 819.012)
A vehicle that is declared a total loss by an insurer who is obligated to cover the loss or a vehicle that the insurer
takes possession of or title to.
A vehicle that has sustained damage that is not covered by an insurer and the estimated cost to repair the vehicle
is equal to at least 80% of the retail market value prior to the damage. “Retail market value” is defined as the
amount shown in publications used by financial institutions (banks or lenders) in this state.
A vehicle that is stolen, if it is not recovered within 30 days of theft and the loss is not covered by an insurer. In this
situation, you must notify DMV within 60 days of the theft.
•
•
•
▼▼
DO NOT WRITE IN
THIS SPACE
Accident
Number
STK# 300009
TIME OF DAY
AM
PM
ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )
COUNTYACCIDENT DATE
M T W TH F
S SN
MILE POST
DAY OF WEEK
WITHIN
NEAR
FEET
MILES
N S E W
N S E W
NAME OF NEAREST INTERSECTING ROAD
WITHIN
NEAR
FEET
MILES
N S E W
N S E W
NAME OF NEAREST CITY / TOWN
TYPE OF ACCIDENT - The accident involved one or more of the following:(Mark all that apply)
Fatality
Bicycle
Pedestrian
More than two vehicles
Two vehicles
Motorized Scooter
Motorcycle
ATV / Snowmobile
Train
Personal (assisted)
Parked vehicle
Fixed object / property
Animal
Overturned vehicle
I certify all information given on this report is true and accurate to the best of my knowledge.
SIGNATURE OF PERSON MAKING REPORT
X
PRINTED NAME OF PERSON MAKING REPORTDAYTIME PHONE #
( )
DATE SIGNED
SECTION 1
SECTION 5
Complete ALL of this section. If you fail to do so, your driving privileges may be suspended. You MUST list the insurance company (not
agent) and policy number that provided liability coverage for the vehicle you were driving.
DRIVER’S NAME (LAST, FIRST, MIDDLE)
DRIVER’S RESIDENCE ADDRESS
CITY
ETATSREBMUNESNECILS’REVIRD
ZIP CODESTATE
DATE OF BIRTHSEX
IF ADDRESS
CHANGE
SECTION 2 (YOUR VEHICLE # 1)
Other ____________________
mobility device
IF ADDITIONAL VEHICLES WERE INVOLVED IN THE ACCIDENT, USE ATTACHED SUPPLEMENTAL REPORT (Form 735-32B).
DESCRIBE WHAT HAPPENED: (IF MORE SPACE IS NEEDED, SUBMIT ADDITIONAL PAGE)
STATEVEHICLE IDENTIFICATION NUMBERVEHICLE PLATE NUMBERMAKE & MODELYEAR
CITY
DRIVER’S LICENSE NUMBER
CITY
STATE
ZIP CODESTATE
DATE OF BIRTH
ZIP CODESTATE
SEX
SECTION 3
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS
POLICY NUMBER
DRIVER’S NAME (LAST, FIRST, MIDDLE)
DRIVER’S ADDRESS
VEHICLE OWNER’S NAME AND ADDRESS
SAME
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS
POLICY NUMBER
STATEVEHICLE IDENTIFICATION NUMBER
VEHICLE PLATE NUMBERMAKE & MODELYEAR
VEHICLE OWNER’S NAME AND ADDRESS
CITY
SAME
ZIP CODESTATE
EDOCPIZYTICSTATE
SECTION 4 (OTHER VEHICLE # 2)
MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE)
EDOCPIZYTICSTATE
Check all
statements
that apply:
Name of police department: __________________________________
A citation was issued to you. The citation was: ________________________________________________________
Damage to your vehicle was more than $1500.
Damage to any one person’s property (other than vehicle) was more than $1500.
Your vehicle was towed from the scene as a result of damages.
You or passengers in your vehicle were injured.
The accident occurred while you were driving your employer’s vehicle.
You were driving on your job and being paid for the principal purpose of driving.
You were being paid to drive and/or deliver persons or property.
You were operating a government owned vehicle marked for transporting mail in accordance with government rules.
You were operating an authorized emergency vehicle.
You were operating a commercial motor vehicle requiring you to have a commercial driver license.
City County
State Police
OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT
DMV
CompletethisformONLYifyouraccidenthappenedon a highwayorpremisesopentothepublic,andresultedinany of thefollowing: 1)
Morethan$1500indamagetoyourvehicle;2)Morethan$1500indamagetoanyoneperson'spropertyotherthan a vehicle;3)Anyvehicle
hasmorethan$1500andanyvehicleistowedfromthesceneasa resultofdamages;4)Injurytoanyperson(nomatterhowminor the
injury); or, 5) the death of any person.
COMPLETE BOTH SIDES
CHECK BOX
IF NOT DRIVER’S SIGNATURE, STATE RELATIONSHIP
REASON DRIVER IS UNABLE TO SIGN REPORTPHONE NUMBER OF DRIVER
( )
735-32 (4-15)
COMPLETE THE OTHER SIDE OF THIS PAGE
You were transporting hazardous material.
A police officer came to the scene.
The accident occurred in a work or maintenance zone.
YOU INTENDED TO...
DiagramVehicle Damage
YOUR VEHICLEYOUR RESIDENCE
Passenger car, pickup, van
Military vehicle
Taxicab
Emergency vehicle
Any of the above and trailer
Private or public agency
transit vehicle
Bus
School bus
Other publicly-owned veh.
Motorcycle
Motor–scooter/bike
Personal (assisted) mobility device
Truck tractor & semi trailer
Truck/truck tractor
Other truck combination
Farm tractor/farm equip.
WEATHER CONDITIONS
Clear
Raining
Snowing
Fog
Other
Local resident
(within 25 miles of accident site)
Residing elsewhere in state
Non–resident of this state:
LIGHT CONDITIONS
Daylight
Dawn or dusk
Darkness (lighted)
Darkness (unlighted)
Other
ROAD SURFACE
Dry
Wet
Snowy
Icy
Other
Go straight ahead
Make right turn
Make left turn
Make “U” turn
Back–Up
Enter driveway (also
mark left or right turn)
Remain stopped in traffic
Enter parked position
Slow or Stop
Leave driveway (also
mark left or right turn)
Start in traffic lane
Leave parked position
Remain parked
Overtake and pass
Number each vehicle:
Show path by:
Show pedestrian/bicyclist by:
Show railroad tracks by:
2
1
N
(name of street,
road or route)
L
(name of street,
road or route)
L
(name of street,
road or route)
R
If this accident involved a pedestrian or
bicyclist, complete the following:
WITNESS INFORMATION:
L
N
JF
H
S
WE
OTHER DRIVER WAS HEADED
(name of street, road or route)
East
West
On: ____________________
North
South
YOU WERE HEADED
(name of street, road or route)
East
West
On: ____________________
College student
Military
Temporary job
ALONG OR ACROSS: (name of street, road or route)
Pedestrian or bicyclist was going:
NSEW
EXAMPLE:
(From: NE corner To: SE corner (or) From: East side To: West side, etc.)
From:
To:
(specify)
North
South
Sex and age of pedestrian / bicyclist:
Age: _____Female
Deceased
Incapacitated
Visible injury
Extent of pedestrian / bicyclist injury:
Momentary unconscious-
ness /complaint of pain
No apparent injury
Crossing at intersection or crosswalk
Crossing not at intersection or crosswalk
Walking / riding in roadway with traffic
Walking / riding in roadway against traffic
Standing in roadway
Pushing or working on vehicles in roadway
Other working in road
Playing in road
Hitchhiking
Not in roadway
Other________________________________
Pedestrian / bicyclist action: (mark one)
FRONT
Your Vehicle (No. 1) damage: $ __________ .
USE ARROW TO SHOW
FIRST IMPACT (SHADE
IN DAMAGED AREA)
Vehicle towed
Rollover
Under car
Totaled
Unknown
Male
BICYCLIST NAMEPEDESTRIAN NAME
Use only for vehicles with middle row of seats (i.e., vans, SUVs, etc.)
SEAT
POSITION
DRIVER
PASSENGER’S NAMES (your vehicle)
EQP
INJURY
DABC
SEXAGE
SFTY
BAG
AIR
FRONT
CENTER
FRONT
RIGHT
MIDDLE
LEFT
MIDDLE
CENTER
MIDDLE
RIGHT
REAR
LEFT
REAR
CENTER
REAR
RIGHT
*
*
*
*
DRIVER AND PASSENGER INJURY AND SAFETY EQUIPMENT INFORMATION
WRITE one of the codes (1–5) in column D
INJURY CODE FOR OCCUPANTSSAFETY EQUIPMENT CODES
WRITE one of the codes (0–10) in column C
0
1
2
3
4
5
6
7
8
9
No seat belt available
Seat belt available but NOT used
Seat belt available and in use
Child restraint device available
Child restraint device in use
Child restraint device not available
Helmet NOT in use
Helmet in use
Air bag deployed
Air bag available - NOT deployed
Air bag NOT available
1
2
3
4
5
10
1
2
3
4
5
21
2
4
1
Deceased as a result of the accident
Incapacitated - unconscious, could not walk,
broken or distorted limbs, etc.
Visible injury - lump, abrasion cuts
Momentary unconsciousness, complaint of
pain, nausea, limping
No apparent injury
3UPPLEMENTALFORMORETHANTWODRIVERSINVOLVEDINTHECRASH
!TTACHTHISFORMTOYOUROREGON TRAFFIC ACCIDENT AND INSURANCE REPORT.
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SUPPLEMENTAL REPORT
OREGON TRAFFIC ACCIDENT
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OREGON DEPARTMENT OF TRANSPORTATION
ACCIDENT REPORTING UNIT
DRIVER AND MOTOR VEHICLE SERVICES
1905 LANA AVE. NE
SALEM OR 97314
FAX: (503) 945-5267
MOTOR CARRIER CRASH REPORT
INSTRUCTIONS: IF YOU CHECKED A BOX UNDER THE QUALIFYING VEHICLE COLUMN AND A BOX UNDER THE CRITERIA COLUMN, COMPLETE THE REMAINDER OF
THE MOTOR CARRIER CRASH REPORT AND SUBMIT TO THE ADDRESS SHOWN ABOVE. IF NO CIRCUMSTANCES LISTED UNDER THE CRITERIA COLUMN APPLY, YOU
ARE NOT REQUIRED TO SUBMIT THE MOTOR CARRIER CRASH REPORT.
,)<28+$9($1<48(67,2165(*$5',1*),//,1*2877+(02725&$55,(5&5$6+
5(32573/($6(&$//
QUALIFYING VEHICLE
COMMERCIAL TRUCK (GVWR OVER 10,000 LBS OR ACTUAL WT
AT TIME OF CRASH EVEN IF GVWR IS SET UNDER 10,000 LBS )
HAZARDOUS MATERIAL PLACARD
COMMERCIAL BUS (DESIGNED FOR 8 OR MORE PASSENGERS)
FARM TRUCK INTERSTATE (OVER 10,000 LBS.)
FARM TRUCK FOR-HIRE (4 OR MORE AXLES)
FARM TRUCK TOWING TRIPLE TRAILERS
FARM TRUCK (OVER 80,000 LBS.)
CRITERIA
ANY PERSON SUSTAINING A FATALITY (WITHIN 30 DAYS OF THE
ACCIDENT)
ANY PERSON SUSTAINING INJURIES REQUIRING TREATMENT AWAY
FROM THE SCENE
ANY VEHICLE INCURRING DISABLING DAMAGE REQUIRING
REMOVAL FROM THE SCENE BY A TOW TRUCK OR ANOTHER
MOTOR VEHICLE
MOTOR CARRIER NAMEAUTHORITY/FILE NUMBER
ADDRESSCITYSTATEZIP CODE
DRIVER INFORMATION
DRIVER NAME (LAST, FIRST, MIDDLE)DATE OF BIRTH
CDL /DL NUMBERSTATEEXPIRATION DATE OF MEDICAL CERTIFICATE
COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE ACCIDENT.
AT TIME OF THE ACCIDENT, TOTAL HOURS
DRIVING SINCE LAST OFF-DUTY PERIOD.
TOTAL HOURS ON DUTY DURING THE PREVIOUS
(FILL OUT ONE ONLY, BASED ON TIME DOCUMENTS)
7 CONSECUTIVE DAYS ____________
8 CONSECUTIVE DAYS ____________
45
US DOT NUMBER
TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)DOES YOUR DRIVER HAVE A MEDICAL WAIVER
YES NO
DRIVER INJURY INFORMATION
RELIEF DRIVER INJURED
YES NO
RELIEF DRIVER KILLEDTOTAL NUMBER OF PASSENGERS
YES NO
YOUR DRIVER INJURED
YES NO
_____KILLED _____ INJURED
YES NO
YOUR DRIVER KILLED
LICENSE CLASS
LENGTH OF EMPLOYMENT
YEARSMONTHS
$%&'0
VEHICLE TYPE (SELECT APPROPRIATE TYPE)
Triples (tractor with 3 trailers
Triples (truck with 2 trailers)
Straight truck-full trailer
Doubles (any)
Heavy Haul
Bus/Van (8 or more
passenger capacity)
Auto/Pickup
MOTOR CARRIER VEHICLE INFORMATION
YEARMAKE
UNIT NUMBER
TOTAL NO. OF AXLES
I
NCLUDING TRAILERS
TRUCK/TRACTOR/BUS LICENSE PLATE NO. & STATE
OTHER MOTOR CARRIER INFORMATION (IF 2 OR MORE MOTOR CARRIERS WERE INVOLVED)
02725&$55,(51$0(9(+,&/(/,&(16($1'67$7('5,9(561$0('5,9(56/,&(16($1'67$7(
OTHER DRIVER INJURY INFORMATION
TOTAL NUMBER OF PEDESTRIANS
_____KILLED _____ INJURED
TOTAL NUMBER OF OTHER DRIVERS
_____KILLED _____ INJURED
TOTAL NUMBER OF OTHER PASSENGERS
_____KILLED _____ INJURED
TOTAL NUMBER OF BICYCLISTS
_____KILLED _____ INJURED
Standard
Tractor/Semi Trailer
Straight Truck
Bobtail
Saddlemount
&203/(7(5(9(56(6,'(
DESCRIPTION OF ACCIDENT BY CARRIER OFFICIAL
DID YOUR VEHICLE STRIKE A PARKED VEHICLEWAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE
YES NO
YES NO
COMMODITY INFORMATION
COMMODITY BEING TRANSPORTED AT TIME OF CRASH
WAS A HAZARDOUS COMMODITY BEING HAULED
WAS HAZARDOUS MATERIAL RELEASED FROM
THE VEHICLE CARGO(NOT A FUEL RELEASE)
YES NO
YES NO
HAZARD CLASS
CARGO BODY TYPE (CIRCLE ONE)
VAN FLATBED TANKER CONTAINER POLE DUMP BELLY-DUMP CAR CARRIER LIVESTOCK
MOBILE HOME TOTER PASSENGER DROP-BOX GARBAGE BULK-HOPPER MIXER SADDLEMOUNT
WRECKER FIXED LOAD HEAVY HAUL UTILITY
TOTAL LENGTH OF VEHICLE/COMBTOTAL WIDTH OF VEHICLE OR CARGOCARGO WEIGHTGROSS VEHICLE WEIGHT
DESCRIBE WHAT HAPPENED BY CHECKING ALL BOXES THAT APPLY. YOUR VEHICLE IS ALWAYS NO.1. IF OTHER VEHICLES WERE INVOLVED, COMPLETE
COLUMNS 2 & 3 TO CORRESPOND TO THE ACTIONS OF THE SAME NUMBERED VEHICLES LISTED ABOVE UNDER "OTHER DRIVER INFORMATION".
(FROM SHOULDER,
MEDIAN, PARKING STRIP OR PRIVATE DRIVE)
VEHICLESACTIONVEHICLESACTIONVEHICLESACTION
1 2 3 1 2 3 1 2 3
PASSING
CHANGING LANES
SIDESWIPE
HEAD-ON
SKIDDING
VEHICLE OUT OF CONTROL
ROLL-AWAY
CONTROLLED RR CROSSING
UNCONTROLLED RR CROSSING
RAN OFF ROAD
JACKKNIFE
OVERTURN
SEPARATION OF UNITS
FIRE
EXPLOSION
CARGO SHIFT
CARGO SPILL (HAZARDOUS)
CARGO SPILL (NON-HAZARDOUS)
OTHER (DEER, GUARDRAIL, ETC)
SLOWING - STOPPING
STOPPED
REAR-END
BACKING
MAKING RIGHT TURN
MAKING LEFT TURN
MAKING U TURN
PROCEEDING STRAIGHT
INTERSECTION
ENTERING TRAFFIC
CONDITIONS AT TIME OF ACCIDENT
WEATHER (CIRCLE ONE)
ROAD SURFACE (CIRCLE ONE)
LIGHT CONDITION (CIRCLE ONE)
1. CLEAR
1. DRY
1. DAY
2. RAIN
2. WET
2. DAWN
3. SNOW
3. SNOWY
3. DUSK
4. CLOUDY
4. ICY
4. ARTIFICIAL LIGHTS
5. SLEET
5. OTHER
6. FOG
5. DARK
7. OTHER
6. OTHER
CRASH INFORMATION
LOCATION OF CRASH (NEAREST CITY OR TOWN)HIGHWAY AND MILEPOINT/STREET/COUNTY ROADDIRECTION OF YOUR VEHICLE (CIRCLE)
N S E W
DATE OF CRASHTIME DAY OF THE WEEK (CIRCLE ONE)
MON TUES WED THU FRI SAT SUN
AM
PM
NAME AND TITLE OF PERSON SIGNING REPORTTELEPHONE NUMBER(S)
SIGNATURE I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE
DATE
RED INK MARGINALS (AT BOTTOM):
INSTRUCTIONS
DMV COPY
CUSTOMER COPY
SUPPLEMENTAL REPORT – USE IF MORE THAN TWO VEHICLES
SUPPLEMENTAL – MOTOR CARRIER CRASH REPORT
