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OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT
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:
• Damage to your vehicle is over $2500
• Damage to any one person’s property over $2500
• Injury (No matter how minor)
• Any vehicle has damage over $2500 and any vehicle
is towed from the scene as a result of damages
• Death
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.

INSTRUCTIONS
PRINT OR TYPE ALL INFORMATION. (Use black or dark blue ink and press firmly.)
• 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.

SECTION 1
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.

SECTION 2

YOUR VEHICLE (# 1) — DMV will consider your accident uninsured if you do not complete ALL of this section. You must
list the insurance company name (not agent) and policy number that provided liability coverage for your operation of the
vehicle you were driving at the time of the accident. Note the coverage is for liability insurance, not collision or
comprehensive coverage. DMV will verify this information with the insurance company. If the insurance company denies
the coverage, DMV will suspend your Oregon driving privileges.

SECTION 3
Answer all of the questions in Section 3. DMV will use the information provided in these questions to code the accident. It
is important for you to understand “principal purpose of driving” and “paid to drive.” These include ONLY persons
employed or being paid for the purpose of driving, NOT driving to reach a destination to perform a service. Property
includes, but is not limited to, fixed or real property, landscaping, signs, parked vehicles, and animals.
COMMERCIAL MOTOR VEHICLE OPERATORS: In addition to this report, Oregon Administrative Rule requires that
Form 735-9229, Motor Carrier Crash Report, MUST be filed within 30 days of a commercial motor vehicle accident
when there is a FATALITY, INJURY (requiring treatment away from the scene), or when a vehicle is TOWED from the
scene because of disabling damage. Form 735-9229 (attached on back) MUST be submitted with Oregon Traffic Accident
and Insurance Report (Form 735-32) to DMV. Call (503) 986-3507 for questions regarding the Motor Carrier Crash Report.

SECTION 4
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).

SECTION 5
DESCRIPTION AND SIGNATURE — Describe what happened. It is important for you to sign and date the form.

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.
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.
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.
MAIL — Mail the form to Accident Reporting Unit, DMV, 1905 Lana Ave NE, Salem OR 97314 or FAX to (503) 9455267, or deliver it to any DMV office.
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.
STK# 300009

735-32 (1-18)

INSTRUCTIONS

TOTALED VEHICLE NOTICE
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
“Totaled Vehicle” or “Totaled” as defined in Oregon law (ORS 801.527) means:

•

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.

▼

FOLLOW THESE INSTRUCTIONS IF YOUR VEHICLE IS TOTALED

▼

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)

OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT
COMPLETE BOTH SIDES

SECTION 1

Complete this form ONLY if your accident happened on a highway or premises open to the public, and resulted in any of the following: 1)
More than $2500 in damage to your vehicle; 2) More than $2500 in damage to any one person's property other than a vehicle; 3) Any vehicle
has more than $2500 and any vehicle is towed from the scene as a result of damages; 4) Injury to any person (no matter how minor the
injury); or, 5) the death of any person.
DAY OF WEEK TIME OF DAY
ACCIDENT DATE
COUNTY
DO NOT WRITE IN Accident
M T W TH F
AM
Number
THIS SPACE
S SN
PM
ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )

WITHIN

FEET

N S

E W

NEAR

MILES N S

E W

WITHIN

FEET

N S

E W

NEAR

MILES N S

E W

MILE POST

TYPE OF ACCIDENT - The accident involved one or more of the following: (Mark all that apply)

NAME OF NEAREST INTERSECTING ROAD

Two vehicles

ATV / Snowmobile

Parked vehicle

More than two vehicles

Motorcycle

Overturned vehicle

Fatality

Motorized Scooter
Personal (assisted)
mobility device
Train

Animal

Bicycle

NAME OF NEAREST CITY / TOWN

Pedestrian

Fixed object / property
Other ____________________

SECTION 2 (YOUR VEHICLE # 1)

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 LICENSE NUMBER

DRIVER’S RESIDENCE ADDRESS

CITY

STATE

ZIP CODE

MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE)

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

STATE

YEAR

DATE OF BIRTH

SEX (CIRCLE)

F X
CHECK BOX
IF ADDRESS
CHANGE

SAME
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS

POLICY NUMBER

SECTION 3

Check all
statements
that apply:

SECTION 4 (OTHER VEHICLE # 2)

STATE

VEHICLE PLATE NUMBER

VEHICLE IDENTIFICATION NUMBER

MAKE & MODEL

Damage to your vehicle was more than $2500.
Damage to any one person’s property (other than vehicle) was more than $2500.
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.
You were transporting hazardous material.
The accident occurred in a work or maintenance zone. ORS 811.230
A police officer came to the scene.
Name of police department: __________________________
City
County
State Police
A citation was issued to you. The citation was: ________________________________________________________

DRIVER’S NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

STATE

YEAR

STATE

DATE OF BIRTH

SEX (CIRCLE)

F X

SAME
INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS

POLICY NUMBER

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

MAKE & MODEL

IF ADDITIONAL VEHICLES WERE INVOLVED IN THE ACCIDENT, USE ATTACHED SUPPLEMENTAL REPORT (Form 735-32B).

SECTION 5

DESCRIBE WHAT HAPPENED: (IF MORE SPACE IS NEEDED, SUBMIT ADDITIONAL PAGE)

I certify all information given on this report is true and accurate to the best of my knowledge.
SIGNATURE OF PERSON MAKING REPORT

X
IF NOT DRIVER’S SIGNATURE, STATE RELATIONSHIP

PRINTED NAME OF PERSON MAKING REPORT

REASON DRIVER IS UNABLE TO SIGN REPORT

DAYTIME PHONE #

(

DATE SIGNED

)

PHONE NUMBER OF DRIVER

(
735-32 (1-18)

COMPLETE THE OTHER SIDE OF THIS PAGE

)
STK# 300009

DMV COPY

YOU INTENDED TO...

YOUR VEHICLE

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

WEATHER CONDITIONS

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.

Clear
Raining
Snowing
Fog
Other

YOUR RESIDENCE

Local resident
(within 25 miles of accident site)

Residing elsewhere in state
Non–resident of this state:
College student
Military
Temporary job

ROAD SURFACE

Dry
Wet
Snowy
Icy
Other

YOU WERE HEADED

North
South

On: ____________________

LIGHT CONDITIONS

(name of street, road or route)

Daylight
Dawn or dusk
Darkness (lighted)
Darkness (unlighted)
Other

WITNESS INFORMATION:

OTHER DRIVER WAS HEADED

North
South

(name of street, road or route)

If this accident involved a pedestrian or
bicyclist, complete the following:

WRITE one of the codes (1–5) in column D

1. Deceased as a result of the accident
2. Incapacitated - unconscious, could not walk,
broken or distorted limbs, etc.
3. Visible injury - lump, abrasion cuts
4. Momentary unconsciousness, complaint of
pain, nausea, limping
5. No apparent injury

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

SEX CODE

WRITE M, F or X in column A
A

PASSENGER’S NAMES (your vehicle)

SEX

DRIVER
FRONT
RIGHT

*
*
MIDDLE *
RIGHT
MIDDLE
LEFT

MIDDLE
CENTER

REAR
LEFT
REAR
CENTER
REAR
RIGHT

FRONT
USE ARROW TO SHOW
FIRST IMPACT (SHADE
IN DAMAGED AREA)

C
SFTY
EQP

D
AIR
BAG

INJURY

From:
To:
EXAMPLE: (From: NE corner To: SE corner (or) From: East side To: West side, etc.)

Sex and age of pedestrian / bicyclist:
X
M
F
Age: _____
Extent of pedestrian / bicyclist injury:
Momentary unconsciousDeceased
ness / complaint of pain
Incapacitated
No apparent injury
Visible injury
Pedestrian / bicyclist action: (mark one)
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________________________________

FRONT
CENTER

* Use only for vehicles with middle row of seats (i.e., vans, SUVs, etc.)
Vehicle Damage
Diagram

B
AGE

(specify)

Number each vehicle:
Show path by:
Show pedestrian/bicyclist by:
Show railroad tracks by:



Vehicle towed
Rollover
Under car
Totaled
Unknown

Your Vehicle (No. 1) damage: $ __________ .

ALONG OR ACROSS: (name of street, road or route)

(name of street,
road or route)

WRITE one of the codes (0–10) in column C

BICYCLIST NAME

Pedestrian or bicyclist was going:
N
S
E

DRIVER AND PASSENGER INJURY AND SAFETY EQUIPMENT INFORMATION
SAFETY EQUIPMENT CODES
INJURY CODE FOR OCCUPANTS

SEAT
POSITION

East
West

On: ____________________

PEDESTRIAN NAME

0
1
2
3
4
5
6
7
8
9
10

East
West

SUPPLEMENTAL REPORT
OREGON TRAFFIC ACCIDENT
Supplemental for more than two drivers involved in the crash.
Attach this form to your OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT.
ACCIDENT DATE

DAY OF WEEK TIME OF DAY
COUNTY
M T W TH F
AM
S SN
PM
ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )

VEHICLE

MILE POST

DO NOT WRITE
IN THIS SPACE
POLICY NUMBER

INSURANCE COMPANY NAME (NOT AGENCY)

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

DATE OF BIRTH

STATE

SEX (CIRCLE)

F X

SAME
VEHICLE

POLICY NUMBER

INSURANCE COMPANY NAME (NOT AGENCY)

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

STATE

MAKE & MODEL

DATE OF BIRTH

SEX (CIRCLE)

F X

SAME
VEHICLE

POLICY NUMBER

INSURANCE COMPANY NAME (NOT AGENCY)

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

STATE

YEAR

MAKE & MODEL

DATE OF BIRTH

STATE

SEX (CIRCLE)

F X

SAME
VEHICLE

POLICY NUMBER

INSURANCE COMPANY NAME (NOT AGENCY)

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

STATE

MAKE & MODEL

DATE OF BIRTH

SEX (CIRCLE)

F X

SAME
VEHICLE

POLICY NUMBER

INSURANCE COMPANY NAME (NOT AGENCY)

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

DRIVER’S ADDRESS

CITY

STATE

ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY

STATE

ZIP CODE

STATE

MAKE & MODEL

DATE OF BIRTH

SEX (CIRCLE)

F X

SAME

735-32B (7-17)

STK# 300026

SUPPLEMENTAL REPORT – USE IF MORE THAN TWO VEHICLES

MOTOR CARRIER CRASH REPORT

OREGON DEPARTMENT OF
TRANSPORTATION ACCIDENT REPORTING
UNIT DRIVER AND MOTOR VEHICLE SERVICES
1905 LANA AVE. NE
SALEM OR 97314
FAX: (503) 945-5267

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. IF YOU HAVE ANY QUESTIONS REGARDING FILLING OUT THE MOTOR CARRIER CRASH
REPORT, PLEASE CALL (503) 986-3507.

QUALIFYING VEHICLE

CRITERIA

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.)

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 NAME

US DOT NUMBER

AUTHORITY/FILE NUMBER

ADDRESS

CITY

STATE

ZIP CODE

DRIVER INFORMATION
DRIVER NAME (LAST, FIRST, MIDDLE)

DATE OF BIRTH

LENGTH OF EMPLOYMENT
YEARS

CDL / DL NUMBER

STATE

LICENSE CLASS
A

MONTHS

EXPIRATION DATE OF MEDICAL CERTIFICATE
C

COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE ACCIDENT.
7 CONSECUTIVE DAYS ____________
8 CONSECUTIVE DAYS ____________

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)

DOES YOUR DRIVER HAVE A MEDICAL WAIVER

TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)

YES

DRIVER INJURY INFORMATION
YOUR DRIVER KILLED

YES

YOUR DRIVER INJURED

YES

RELIEF DRIVER KILLED

YES

RELIEF DRIVER INJURED

YES

TOTAL NUMBER OF PASSENGERS

_____KILLED

_____ INJURED

OTHER DRIVER INJURY INFORMATION
TOTAL NUMBER OF OTHER DRIVERS
_____KILLED

_____ INJURED

TOTAL NUMBER OF OTHER PASSENGERS
_____KILLED

OTHER MOTOR CARRIER INFORMATION
MOTOR CARRIER NAME

_____ INJURED

TOTAL NUMBER OF PEDESTRIANS

TOTAL NUMBER OF BICYCLISTS

_____KILLED

_____ INJURED

(IF 2 OR MORE MOTOR CARRIERS WERE INVOLVED)

VEHICLE LICENSE # AND STATE

DRIVER'S NAME

DRIVER'S LICENSE # AND STATE

MOTOR CARRIER VEHICLE INFORMATION
YEAR

MAKE

UNIT NUMBER

TRUCK/TRACTOR/BUS LICENSE PLATE NO. & STATE

TOTAL NO. OF AXLES
INCLUDING TRAILERS

VEHICLE TYPE (SELECT APPROPRIATE
TYPE)
Heavy Haul

Triples (tractor with 3 trailers

Standard
Tractor/Semi Trailer

Triples (truck with 2 trailers)

Straight Truck

Bus/Van (8 or more
passenger capacity)

Bobtail

Auto/Pickup

735-9229 (4-15)

Straight truck-full trailer

Doubles (any)

Saddlemount

COMPLETE REVERSE SIDE

SUPPLEMENTAL – MOTOR CARRIER CRASH REPORT

CARGO BODY TYPE (CIRCLE ONE)

VAN

FLATBED

TANKER

CONTAINER

POLE

MOBILE HOME TOTER
PASSENGER
DROP-BOX
WRECKER
FIXED LOAD
HEAVY HAUL
UTILITY
TOTAL LENGTH OF VEHICLE/COMB

DUMP

BELLY-DUMP

GARBAGE

CAR CARRIER

BULK-HOPPER

TOTAL WIDTH OF VEHICLE OR CARGO

MIXER

CARGO WEIGHT

LIVESTOCK
SADDLEMOUNT
GROSS VEHICLE WEIGHT

COMMODITY INFORMATION
COMMODITY BEING TRANSPORTED AT TIME OF CRASH
WAS A HAZARDOUS COMMODITY BEING HAULED

YES

HAZARD CLASS

WAS HAZARDOUS MATERIAL RELEASED FROM
THE VEHICLE CARGO(NOT A FUEL RELEASE)

YES

CRASH INFORMATION
LOCATION OF CRASH (NEAREST CITY OR TOWN)

HIGHWAY AND MILEPOINT/STREET/COUNTY ROAD

DIRECTION OF YOUR VEHICLE (CIRCLE)

N
DATE OF CRASH

TIME

AM
PM

DAY OF THE WEEK (CIRCLE ONE)

MON

TUES

WED

THU

FRI

SAT

SUN

CONDITIONS AT TIME OF ACCIDENT
WEATHER (CIRCLE ONE)

1. CLEAR

2. RAIN

3. SNOW

4. CLOUDY

5. SLEET

ROAD SURFACE (CIRCLE ONE)

1. DRY

2. WET

3. SNOWY

4. ICY

5. OTHER

LIGHT CONDITION (CIRCLE ONE)

1. DAY

2. DAWN

3. DUSK

4. ARTIFICIAL LIGHTS

6. FOG

7. OTHER

5. DARK

6. OTHER

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".
VEHICLES

1 2

ACTION

VEHICLES

1 2

ACTION

VEHICLES

1 2

ACTION

SLOWING - STOPPING

PASSING

JACKKNIFE

STOPPED

CHANGING LANES

OVERTURN

REAR-END

SIDESWIPE

SEPARATION OF UNITS

BACKING

HEAD-ON

FIRE

MAKING RIGHT TURN

SKIDDING

EXPLOSION

MAKING LEFT TURN

VEHICLE OUT OF CONTROL

CARGO SHIFT

MAKING U TURN

ROLL-AWAY

CARGO SPILL (HAZARDOUS)

PROCEEDING STRAIGHT

CONTROLLED RR CROSSING

CARGO SPILL (NON-HAZARDOUS)

INTERSECTION

UNCONTROLLED RR CROSSING

OTHER (DEER, GUARDRAIL, ETC)

ENTERING TRAFFIC (FROM SHOULDER,
MEDIAN, PARKING STRIP OR PRIVATE DRIVE)

RAN OFF ROAD

DID YOUR VEHICLE STRIKE A PARKED VEHICLE

YES

WAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE

YES

DESCRIPTION OF ACCIDENT BY CARRIER OFFICIAL

NAME AND TITLE OF PERSON SIGNING REPORT

TELEPHONE NUMBER(S)

SIGNATURE I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE

DATE

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Instance ID                     : uuid:845c38fd-36db-43c6-bce4-be2d49ef7523
Version                         : 11.0.0.20130303.1.892433
Version Ref                     : /template/subform[1]
Embedded Href                   : C:\Users\mv17\Desktop\32 design elements folder\32_graphics_NorthArrow_400.png
Embedded Href Ref               : /template/subform[1]/subform[4]/draw[1069]
Page Count                      : 7

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