MINNESOTA MOTOR VEHICLE ACCIDENT REPORTDRIVER’S TRAFFIC ACCIDENT REPORT FOR STATE USE ONLYTIME/PLACE

MY

VEHICLE

NUMBER

1

VEHICLE

NUMBER

2

A

B

C

DATE OFACCIDENT

MONTH DAY YEAR DAY OF WEEK TIME AM COUNTY AGENCY LOCATION CODE

NAME OF STREET OR ROAD NUMBER CITY

PM

ON: TWP OF

MILESFEET

NS

EW OF:

NAME OF STREET, ROAD NUMBER OR CITYAT INTERSECTIONWITH OR:

STATE AGENCY NAME ADDRESS CITY STATE ZIP CODE TEL. #

DRIVER

VEHICLE

DRIVER’S FULL NAME ADDRESS CITY STATE ZIP CODE TEL. # INJURY

DRIVER’S LICENSE NUMBER CLASS STATE OF ISSUE DATE OF BIRTH SEX RESTRAINT EJECT

CODE*

CODE* CODE*

LICENSE PLATE NUMBER YEAR STATE OF ISSUE PARTS OF VEHICLE VEHICLE NO. 1 ESTIMATED COSTSHOW POINTS OF REPAIRSOF DAMAGE

FRONT

MODEL YEAR MAKE UNIT NO. VIN NUMBER OF OCCUPANTS $

TOTAL # OF VEHICLES INVOLVED THE STATE OF MINNESOTA IS SELF-INSURED/THE POLICY IDENTIFICATION NUMBER IS A-1046

DRIVER

VEHICLE

OTHEROWNER

FULL NAME ADDRESS CITY STATE ZIP CODE TEL. #

OTHERDRIVER

FULL NAME ADDRESS CITY STATE ZIP CODE TEL. # INJURY

DRIVER’S LICENSE NUMBER CLASS STATE OF ISSUE DATE OF BIRTH SEX

CODE*

LICENSE PLATE NUMBER YEAR STATE OF ISSUE PARTS OF VEHICLE VEHICLE NO. 1 ESTIMATED COSTSHOW POINTS OF REPAIRSOF DAMAGE

FRONT

$MODEL YEAR MAKE COLOR TYPE (AUTO, TRUCK, TAXI, ETC.) NUMBER OF OCCUPANTS

NAME OF INSURANCE COMPANY (NOT AGENT) POLICY NUMBER

IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATTACH

DESCRIBE PROPERTY DAMAGED (NOT VEHICLES) APPROXIMATE COST OF REPAIR

$

OWNER OF PROPERTY MAILING ADDRESS *CO

DES

ON

BAC

K

DIRECTIONS

FILL IN THE BOXES NEXTTO THE ARROW BY EN-TERING THE NUMBER OFTHE ITEM WHICH BESTDESCRIBES THE CIRCUM-STANCES OF THE ACCI-DENT.

IF A QUESTION DOESNOT APPLY, ENTER ADASH ( - ).

IF AN ANSWER IS UN-KNOWN, ENTER AN “X.”

TYPE OF ACCIDENT

10 - RR CROSSING GATES11 - RR CROSSING FLASHING LIGHTS12 - RR CROSSING STOP SIGN13 - RRCROSSINGFLASHERS14 - RR OVERHEAD FLASHERS/GATE15 - RR CROSSBUCK90 - DESCRIBE

NON-COLLISION11 - OVERTURN12 - FIRE/EXPLOSION13 - SUBMERSION90 - OTHER (DESCRIBE)

WORK ZONE NOT MARKED5 - CONSTRUCTION6 - MAINTENANCE7 - UTILITY90 - OTHER (DESCRIBE)

COLLISION WITH A(N)1 - MOTOR VEHICLE ON SAME ROADWAY2 - MOTOR VEHICLE ON SEPARATE ROADWAY3 - PARKED MOTOR VEHICLE4 - TRAIN5 - BICYCLIST6 - PEDESTRIAN7 - DEER8 - OTHER ANIMAL9 - FIXED OBJECT10 - FALLING OBJECT (DESCRIBE)

1 - TRAFFIC SIGNAL2 - OVERHEAD FLASHERS3 - STOP SIGN - ALL APPROACHES4 - STOP SIGN - OTHER5 - YIELD SIGN6 - OFFICER/FLAG PERSON, SCHOOL PATROL7 - SCHOOL BUS STOP ARM8 - SCHOOL SIGN ZONE9 - NO PASSING ZONE

TRAFFIC CONTROL DEVICE

ROAD WORK1 - NONEWORK ZONE MARKED2 - CONSTRUCTION3 - MAINTENANCE4 - UTILITY

1

2

3

4

5

6

7

10

11

8

9

FIXED OBJECT STRUCK0 - NOT APPLICABLE1 - CONSTRUCTION EQUIPMENT2 - TRAFFIC SIGNAL3 - RR CROSSING DEVICE4 - LIGHT POLE5 - UTILITY POLE6 - SIGN STRUCTURE/POST7 - MAILBOXES AND/OR POSTS8 - OTHER POLES, ETC.9 - HYDRANT10 - TREE/SHRUBBERY11 -CRASH CUSHION

12 - MEDIAN SAFETY BARRIER13 - BRIDGE/PIER/GUARDRAIL14 - OTHER GUARDRAIL15 - FENCE (NON-MEDIAN BARRIER)16 - CULVERT/HEAD WALL17 - EMBANKMENT/DITCH/CURB16 - BUILDING/WALL19 - ROCK OUTCROPS20 - PARKING METER90 - OTHER (DESCRIBE)

4 - DARK (STREET LIGHTS ON)5 - DARK (STREET LIGHTS OFF)6 - DARK (NO STREET LIGHTS)90 - OTHER (DESCRIBE)

LIGHT1 - DAYLIGHT2 - DAWN (AM)3 - DUSK (PM)

6 - FOG/SMOG/SMOKE7 - BLOWING SAND/DUST/SNOW8 - SEVERE CROSSWINDS90 - OTHER (DESCRIBE)

WEATHER/ATMOSPHERE1 - CLEAR2 - CLOUDY3 - RAIN4 - SNOW5 - SLEET/HAIL/FREEZING RAIN

5 - MUDDY6 - DEBRIS7 - OILY90 - OTHER (DESCRIBE)

ROAD SURFACE1 - DRY2 - WET3 - SNOW/SLUSH4 - ICE/PACKED SNOW

#1

#2

USE BOXES 8 AND 10 FOR YOUR VEHICLE (#1) AS IN SECTION B. USE BOXES 9 AND 11 FOR OTHER VEHICLE (#2) AS IN SECTION C.

#1

#2 5

87

6 43

21

CONTINUEREPORT ONOTHER SIDE

1 - GOING STRAIGHT AHEAD/FOLLOWING ROADWAY2 - WRONG WAY INTO OPPOSING TRAFFIC3 - RIGHT TURN ON RED4 - LEFT TURN ON RED5 - MAKING RIGHT TURN6 - MAKING LEFT TURN7 - MAKING U-TURN8 - STARTING FROM PARKED POSITION9 - STARTING IN TRAFFIC10 - SLOWING IN TRAFFIC11 - STOPPED IN TRAFFIC12 - ENTERING PARKED POSITION13 - PARKED LEGALLY13 - PARKED LEGALLY15 - AVOIDED VEHICLE/OBJECT IN ROAD17 - CHANGING LANE18 - OVERTAKING/PASSING19 - MERGING20 - BACKING21 - STALLED

PRE-ACCIDENT ACTIONS/MANEUVERS- BY VEHICLE - - BY PEDESTRIAN - - BY BYCYCLIST -

41 - CROSSING WITH SIGNAL42 - CROSSING AGAINST SIGNAL43 - CROSSING MARKED CROSSWALK44 - CROSSING (NO SIGNAL OR MARKED CROSSWALK)45 - WALK/RUN IN ROAD WITH TRAFFIC46 - WALK/RUN IN ROAD AGAINST TRAFFIC47 - STANDING IN ROAD48 - EMERGING FROM BEHIND PARKED VEHICLE49 - CHILD GETTING OFF SCHOOL BUS50 - GETTING ON/OFF VEHICLE51 - PUSHING/WORKING ON VEHICLE52 - WORKING IN ROADWAY53 - PLAYING IN ROADWAY54 - NOT IN ROADWAY

71 - RIDING WITH TRAFFIC72 - RIDING AGAINST TRAFFIC73 - MAKING RIGHT TURN74 -MAKING LEFT TURN75 - MAKING U-TURN76 - RIDING ACROSS ROAD77 - SLOWING/STOPPING/STARTING

90 - OTHER ACTION (DESCRIBE)

PRE-ACCIDENT DIRECTION OF TRAVEL1 - NORTH2 - NORTHEAST3 - EAST4 - SOUTHEAST5 - SOUTH6 - SOUTHWEST7 - WEST8 - NORTHWEST

WAS THERE A POLICEOFFICER AT THE SCENE?

YES NO

IF YES, WHAT DEPARTMENT? (NAME OF CITY OR COUNTY) WHAT WAS THE POSTEDSPEED LIMIT AT THE SCENEOF THE ACCIDENT?

Every driver in a crash involving $1,000 or more in property damage, or injury or death, MUST COMPLETE this form and send it to Driver and Vehicle Services within 10 days.Failure to provide this information is a misdemeanor under Minnesota Statute 169.08

The information in this report is used to help build safer roads. MAIL A COPY OF THIS REPORT TO:

DVS/ACCIDENT RECORDS445 MINNESOTA STREET, SUITE 181

ST. PAUL MN 55101-5181

- OCCUPANT SEAT POSITION CODES -1 - FRONT LEFT2 - FRONT CENTER3 - FRONT RIGHT4 - SECOND SEAT LEFT5 - SECOND SEAT CENTER6 - SECOND SEAT RIGHT7 - THIRD SEAT LEFT8 - THIRD SEAT CENTER9 - THIRD SEAT RIGHT10 - OUTSIDE OF VEHICLE11 - STOPPED IN TRAFFIC12 - MOTORCYCLE/SNOWMOBILE/BICYCLE DRIVER13 - MOTORCYCLE/SNOWMOBILE/BICYCLE PASSENGER ON UNIT90 - OTHER (DESCRIBE)

- RESTRAINT DEVICE CODES -1 - SEAT BELT NOT INSTALLED2 - SEAT BELT INSTALLED, NOT USED3 - SEAT BELT INSTALLED, USED4 - SEAT BELT INSTALLED, IMPROPERLY USED5 - AUTOMATIC BELT INSTALLED, USED6 - AUTOMATIC BELT INSTALLED, CIRCUMVENTED7 - AIRBAG USED WITH SEATBELT8 - AIRBAG USED WITHOUT SEATBELT9 - CHILD RESTRAINT NOT INSTALLED10 - CHILD RESTRAINT INSTALLED, NOT USED11 - CHILD RESTRAINT INSTALLED, USED12 - CHILD RESTRAINT IMPROPERLY USED13 - HELMET NOT USED14 - HELMET USED90 - OTHER (DESCRIBE)

- EJECTION CODES -0 - NOT APPLICABLE1 - TRAPPED, EXTRICATED2 - PARTIALY EJECTED3 - EJECTED4 - NOT EJECTED

- INJURY CODES -K - KILLEDA - VISIBLE SIGNS OF INJURY, AS BLEEDING WOUND OR DISTORTED MEMBER, OR HAD TO BE CARRIED FROM THE SCENEB - OTHER VISIBLE INJURY, AS BRUISES, ABRASIONS, SWELLING, LIMPING, ETC.C - NO VISIBLE INJURY BUT COMPLAINT OF PAIN OR MOMENTARY UNCONCIOUSNESSN - NO INDICATION OF INJURYX - UNKNOWN

P

A

S

S

V

E

H

1

DRIVER: Were you on work status? YESNO *CODES ARE ABOVE ON THIS PAGE

P

A

S

S

V

E

H

2

1. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*

2. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*

1. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*

2. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*

DESCRIBE ACCIDENT IN SUFFICIENT DETAIL TO DISCLOSE CAUSES. This is a confidential report for department use only.

DIAGRAM WHAT HAPPENEDINDICATE NORTH

BY ARROW

NAME ADDRESS PHONE

WIT

NESS

ES ( ) NAME ADDRESS PHONE

( ) NAME ADDRESS PHONE

( )

SIGNA

TURE

S EMPLOYEE’S SIGNATURE WORK ADDRESS PHONE( )

SAFETY OFFICERS SIGNATURE (OPTIONAL) WORK ADDRESS PHONE( )

SUPERVISOR’S NAME WORK ADDRESS PHONE( )

CHECK IF PHOTOS WERE TAKEN BY WHOM?

(JULY 2010)