Accident Report Substance

MOTOR VEHICLE
ACCIDENT (CRASH)
REPORT
Please read the
Privacy Act
Statement on Page 4
INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X, items 73
thru 83c are filled out by the operator’s supervisor. Section XI thru XIII are filled out by a crash
investigator for bodily injury, fatality, and/or damage exceeding $500.
SECTION I – FEDERAL VEHICLE DATA
1. DRIVER’S NAME (Last, First, Middle) 2. DRIVER’S LICENSE NUMBER/STATE/LIMITATIONS 3. DATE OF CRASH
4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS 4b. TELEPHONE NUMBER
5. TAG OR IDENTIFICATION NUMBER 6. ESTIMATED REPAIR COST 7. YEAR OF VEHICLE 8. MAKE 9. MODEL 10. SEAT BELTS USED?
11. DESCRIBE VEHICLE DAMAGE
SECTION II – OTHER VEHICLE DATA (Use Section VIII if additional space is needed)
12. DRIVER’S NAME (Last, First, Middle) 13. SOCIAL SECURITY NUMBER/
TAX IDENTIFICATION NUMBER
14. DRIVER’S LICENSE NUMBER/STATE/LIMITATIONS
15a. DRIVER’S WORK ADDRESS 15b. TELEPHONE NUMBER
16a. DRIVER’S HOME ADDRESS 16b. HOME TELEPHONE NUMBER
17. DESCRIPTION OF VEHICLE DAMAGE 18. ESTIMATED REPAIR COST
19. YEAR OF VEHICLE 20. MAKE OF VEHICLE 21. MODEL OF VEHICLE 22. TAG NUMBER AND STATE
23a. DRIVER’S INSURANCE COMPANY NAME AND ADDRESS
24. VEHICLE IS 25a. OWNER’S NAME(S) (Last, First, Middle)
23b. POLICY NUMBER
23c. TELEPHONE NUMBER
25b. TELEPHONE NUMBER
CO-OWNED
LEASED
RENTAL
PRIVATELY OWNED
SECTION III – FATALITY OR INJURED (Use Section VIII if additional space is needed)
A
B
27. NAME (Last, First, Middle) 28. SEX 29. DATE OF BIRTH
30. ADDRESS
31. MARK “X” IN TWO APPROPRIATE BOXES 32. IN WHICH VEHICLE 33. LOCATION IN VEHICLE 34. FIRST AID GIVEN BY
35. TRANSPORTED BY 36. TRANSPORTED TO
37. NAME (Last, First, Middle) 38. SEX 39. DATE OF BIRTH
41. MARK “X” IN TWO APPROPRIATE BOXES 42. IN WHICH VEHICLE 43. LOCATION IN VEHICLE 44. FIRST AID GIVEN BY
45. TRANSPORTED BY 46. TRANSPORTED TO
40. ADDRESS
47.
PEDESTRIAN
a. NAME OF STREET OR HIGHWAY
FROM TO
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF CRASH (crossing intersection with signal, against signal, diagonally; in roadway playing,
walking, hitchhiking, etc.)
YES NO
FATALITY
FATALITY
INJURED
INJURED
DRIVER
DRIVER
HELPER
HELPER
PASSENGER
PASSENGER
PEDESTRIAN
PEDESTRIAN
FED
FED
OTHER (2)
OTHER (2)
26. OWNER’S ADDRESS(ES)
$
$
4c. E-MAIL ADDRESS
1. Number the vehicles involved as follows:
Government Vehicle (GOV) #1 – Private Vehicle (POV) #2 – Additional Vehicles GOV or POV as #3, etc. and show direction of
travel by arrow.
(Example: —-> <—-)
2. Use solid line to show path before crash
Broken line after crash – – – – – – – – – – – –
3. Show pedestrian by ————————>
4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|
5. Give names or numbers of streets or highways
6. Indicate north by arrow in this compass
STANDARD FORM 91 (REV. 9/2020) PAGE 2
SECTION IV – CRASH TIME AND LOCATION (Use Section VII if additional space is needed)
48. DATE OF CRASH 49. PLACE OF CRASH (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business,
residential, open country, etc.); Road description).
50. TIME OF CRASH
AM
PM
51. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED
1 2
2
2
STANDARD FORM 91 (REV. 9/2020) PAGE 3
52. POINT OF IMPACT (Check one for each vehicle)
FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA
a. Front b. Right Front c. Left Front d. Rear e. Right Rear f. Left Rear
g. Right Side h. Left Side
53. DESCRIBE WHAT HAPPENED (Refer to vehicles as “Fed”, “2”, “3”, etc. Please include information on posted speed limit, approximate speed of
vehicles, road conditions, weather conditions, driver visibility, condition of crash vehicles, traffic controls (warning light, stop signal, etc.), condition of light
(daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.).
SECTION V – WITNESS/PASSENGER (Witness must fill out Standard Form 94 – Statement of Witness) (Continue in Section VIII.)
A
B
54. NAME (Last, First, Middle) 55. TELEPHONE NUMBER 56. HOME TELEPHONE NUMBER
57. WORK ADDRESS 58. HOME ADDRESS
62. WORK ADDRESS 63. HOME ADDRESS
59. NAME (Last, First, Middle) 60. TELEPHONE NUMBER 61. HOME TELEPHONE NUMBER
SECTION VI – PROPERTY DAMAGE (Use Section VIII if additional space is needed.)
64a. NAME OF OWNER (Last, First, Middle) 64b. TELEPHONE NUMBER 64c. HOME TELEPHONE NUMBER
64d. WORK ADDRESS 64e. HOME ADDRESS
65a. NAME OF INSURANCE COMPANY 65b. TELEPHONE NUMBER 65c. POLICY NUMBER
66. ITEM DAMAGED 67. LOCATION OF DAMAGED ITEM 68. ESTIMATED COST
SECTION VII – POLICE INFORMATION
69a. NAME OF POLICE OFFICER 69b. BADGE NUMBER 69c. TELEPHONE NUMBER
70. PRECINCT OR HEADQUARTERS 71a. PERSON CHARGED WITH CRASH 71b. VIOLATION(S)
SECTION VIII – EXTRA DETAILS