Minnesota Motor Vehicle Accident Report
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1
2MINNESOTA MOTOR VEHICLE ACCIDENT REPORT
FOR STATE USE ONLY
DRIVER’S TRAFFIC ACCIDENT REPORT
T
A
DATE OF
MONTH
DAY
YEAR
DAY OF WEEK
TIME
AM
COUNTY
AGENCY LOCATION CODE
I
ACCIDENT
PM
M
E
/
NAME OF STREET OR ROAD NUMBER
CITY
P
OF
ON:
TWP
L
A
C
AT INTERSECTION
MILES
N
E
NAME OF STREET, ROAD NUMBER OR CITY
E
OF:
FEET
S
W
WITH
OR:
M
B
STATE AGENCY NAME
ADDRESS
CITY
STATE
ZIP CODE
TEL. #
Y
V
E
D
H
R
DRIVER’S FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
TEL. #
INJURY
I
CODE*
I
C
V
L
E
E
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
RESTRAINT
EJECT
R
CODE*
CODE*
N
V
U
E
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE
VEHICLE NO. 1
ESTIMATED COST
M
SHOW POINTS
OF REPAIRS
H
FRONT
B
OF DAMAGE
I
$
E
C
MODEL YEAR
MAKE
UNIT NO.
VIN
NUMBER OF OCCUPANTS
R
L
1
E
TOTAL # OF VEHICLES INVOLVED
THE STATE OF MINNESOTA IS SELF-INSURED/THE POLICY IDENTIFICATION NUMBER IS A-1046
V
C
OTHER
FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
TEL. #
E
H
OWNER
I
D
C
R
FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
TEL. #
INJURY
OTHER
L
I
CODE*
E
DRIVER
V
E
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
R
N
U
V
M
E
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE
VEHICLE NO. 1
ESTIMATED COST
B
H
SHOW POINTS
OF REPAIRS
FRONT
E
OF DAMAGE
I
$
R
C
MODEL YEAR
MAKE
COLOR
TYPE (AUTO, TRUCK, TAXI, ETC.)
NUMBER OF OCCUPANTS
L
2
E
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
DIRECTIONS
TYPE OF ACCIDENT
FIXED OBJECT STRUCK
COLLISION WITH A(N)
NON-COLLISION
0 - NOT APPLICABLE
12 - MEDIAN SAFETY BARRIER
1 - MOTOR VEHICLE ON SAME ROADWAY
11 - OVERTURN
1 - CONSTRUCTION EQUIPMENT
13 - BRIDGE/PIER/GUARDRAIL
2 - MOTOR VEHICLE ON SEPARATE ROADWAY
12 - FIRE/EXPLOSION
FILL IN THE BOXES NEXT
1
2 - TRAFFIC SIGNAL
14 - OTHER GUARDRAIL
3 - PARKED MOTOR VEHICLE
13 - SUBMERSION
4
3 - RR CROSSING DEVICE
15 - FENCE (NON-MEDIAN BARRIER)
TO THE ARROW BY EN-
4 - TRAIN
90 - OTHER (DESCRIBE)
4 - LIGHT POLE
16 - CULVERT/HEAD WALL
5 - BICYCLIST
TERING THE NUMBER OF
5 - UTILITY POLE
17 - EMBANKMENT/DITCH/CURB
6 - PEDESTRIAN
6 - SIGN STRUCTURE/POST
16 - BUILDING/WALL
THE ITEM WHICH BEST
7 - DEER
7 - MAILBOXES AND/OR POSTS
19 - ROCK OUTCROPS
8 - OTHER ANIMAL
DESCRIBES THE CIRCUM-
8 - OTHER POLES, ETC.
20 - PARKING METER
9 - FIXED OBJECT
STANCES OF THE ACCI-
9 - HYDRANT
90 - OTHER (DESCRIBE)
10 - FALLING OBJECT (DESCRIBE)
10 - TREE/SHRUBBERY
DENT.
11 -CRASH CUSHION
TRAFFIC CONTROL DEVICE
1 - TRAFFIC SIGNAL
10 - RR CROSSING GATES
LIGHT
5
2 - OVERHEAD FLASHERS
11 - RR CROSSING FLASHING LIGHTS
IF A QUESTION DOES
1 - DAYLIGHT
4 - DARK (STREET LIGHTS ON)
2
3 - STOP SIGN - ALL APPROACHES
12 - RR CROSSING STOP SIGN
2 - DAWN (AM)
5 - DARK (STREET LIGHTS OFF)
NOT APPLY, ENTER A
4 - STOP SIGN - OTHER
13 - RRCROSSINGFLASHERS
3 - DUSK (PM)
6 - DARK (NO STREET LIGHTS)
5 - YIELD SIGN
14 - RR OVERHEAD FLASHERS/GATE
DASH ( - ).
90 - OTHER (DESCRIBE)
6 - OFFICER/FLAG PERSON, SCHOOL PATROL
15 - RR CROSSBUCK
WEATHER/ATMOSPHERE
7 - SCHOOL BUS STOP ARM
90 - DESCRIBE
6
1 - CLEAR
6 - FOG/SMOG/SMOKE
IF AN ANSWER IS UN-
8 - SCHOOL SIGN ZONE
2 - CLOUDY
7 - BLOWING SAND/DUST/SNOW
9 - NO PASSING ZONE
KNOWN, ENTER AN “X.”
3 - RAIN
8 - SEVERE CROSSWINDS
ROAD WORK
4 - SNOW
90 - OTHER (DESCRIBE)
3
1 - NONE
WORK ZONE NOT MARKED
5 - SLEET/HAIL/FREEZING RAIN
WORK ZONE MARKED
5 - CONSTRUCTION
ROAD SURFACE
2 - CONSTRUCTION
6 - MAINTENANCE
7
1 - DRY
5 - MUDDY
3 - MAINTENANCE
7 - UTILITY
2 - WET
6 - DEBRIS
4 - UTILITY
90 - OTHER (DESCRIBE)
3 - SNOW/SLUSH
7 - OILY
4 - ICE/PACKED SNOW
90 - OTHER (DESCRIBE)
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.
PRE-ACCIDENT ACTIONS/MANEUVERS
- BY VEHICLE -
- BY PEDESTRIAN -
- BY BYCYCLIST -
8
1 - GOING STRAIGHT AHEAD/FOLLOWING ROADWAY
41 - CROSSING WITH SIGNAL
71 - RIDING WITH TRAFFIC
2 - WRONG WAY INTO OPPOSING TRAFFIC
42 - CROSSING AGAINST SIGNAL
72 - RIDING AGAINST TRAFFIC
#1
#1
3 - RIGHT TURN ON RED
43 - CROSSING MARKED CROSSWALK
73 - MAKING RIGHT TURN
PRE-ACCIDENT DIRECTION OF TRAVEL
4 - LEFT TURN ON RED
44 - CROSSING (NO SIGNAL OR MARKED CROSSWALK)
74 -MAKING LEFT TURN
1 - NORTH
5 - MAKING RIGHT TURN
45 - WALK/RUN IN ROAD WITH TRAFFIC
10
75 - MAKING U-TURN
2 - NORTHEAST
6 - MAKING LEFT TURN
46 - WALK/RUN IN ROAD AGAINST TRAFFIC
76 - RIDING ACROSS ROAD
3 - EAST
7 - MAKING U-TURN
47 - STANDING IN ROAD
77 - SLOWING/STOPPING/STARTING
1
4 - SOUTHEAST
8
2
8 - STARTING FROM PARKED POSITION
48 - EMERGING FROM BEHIND PARKED VEHICLE
5 - SOUTH
#2
9 - STARTING IN TRAFFIC
49 - CHILD GETTING OFF SCHOOL BUS
90 - OTHER ACTION (DESCRIBE)
7
6 - SOUTHWEST
3
9
10 - SLOWING IN TRAFFIC
50 - GETTING ON/OFF VEHICLE
7 - WEST
6
4
11 - STOPPED IN TRAFFIC
51 - PUSHING/WORKING ON VEHICLE
#2
11
8 - NORTHWEST
5
12 - ENTERING PARKED POSITION
52 - WORKING IN ROADWAY
13 - PARKED LEGALLY
53 - PLAYING IN ROADWAY
13 - PARKED LEGALLY
54 - NOT IN ROADWAY
15 - AVOIDED VEHICLE/OBJECT IN ROAD
CONTINUE
17 - CHANGING LANE
WAS THERE A POLICE
IF YES, WHAT DEPARTMENT? (
)
WHAT WAS THE POSTED
NAME OF CITY OR COUNTY
18 - OVERTAKING/PASSING
SPEED LIMIT AT THE SCENE
REPORT ON
OFFICER AT THE SCENE?
19 - MERGING
OF THE ACCIDENT?
20 - BACKING
OTHER SIDE
YES
NO
21 - STALLED
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