GSA Form SF-91 Motor Vehicle Accident Report

GSA Form STANDARD91 or the "Motor Vehicle Accident Report" is a form issued by the U.S. General Services Administration.

The form was last revised in February 1, 2004 and is available for digital filing. Download an up-to-date GSA Form STANDARD91 in PDF-format down below or look it up on the U.S. General Services Administration Forms website.

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INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X,
Please read the
MOTOR VEHICLE
items 73 thru 83c are filled on by the operator's supervisor. Section XI thru XIII are filled out
Privacy Act State-
ACCIDENT REPORT
by an accident investigator for bodily injury, fatality,and/or damage exceeding $500.
ment on Page 3
SECTION I - FEDERAL VEHICLE DATA
1. DRIVER'S NAME (Last, first, middle)
2. DRIVER'S LICENSE NO./STATE/LIMITATIONS
DATE OF ACCIDENT
4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS
4b. WORK TELEPHONE NUMBER
5. TAG OR IDENTIFICATION NUMBER
6. EST. REPAIR COST 7. YEAR OF VEHICLE 8. MAKE
9. MODEL
10. SEAT BELTS USED
YES
NO
$
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 NO./
14. DRIVER'S LICENSE NO./STATE/LIMITATIONS
TAX IDENTIFICATION NO.
15. a DRIVER'S WORK ADDRESS
15b. WORK TELEPHONE NUMBER
16a. DRIVER'SHOME 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. DRIVE'S INSURANCE COMPANY NAME AND ADDRESS
23b. POLICY NUMBER
23c. TELEPHONE NUMBER
24. VEHICLE IS
25a. OWNER'S NAME(S) (Last, first, middle)
25b. TELEPHONE NUMBER
CO-OWNED
RENTAL
LEASED
PRIVATELY OWNED
26. OWNER'S ADDRESS(ES)
SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed)
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
A
FED
KILLED
DRIVER
PASSENGER
HELPER
OTHER (2)
INJURED
PEDESTRIAN
35. TRANSPORTED BY
36. TRANSPORTED TO
37. NAME (last, first, middle)
38. SEX
39. DATE OF BIRTH
40. ADDRESS
B
41. MARK "X" IN TWO APPROPRIATE BOXES
43. LOCATION IN VEHICLE
44. FIRST AID GIVEN BY
42. IN WHICH VEHICLE
KILLED
DRIVER
PASSENGER
FED
INJURED
HELPER
PEDESTRIAN
OTHER (2)
45. TRANSPORTED BY
46. TRANSPORTED TO
a. NAME OF STREET OR HIGHWAY
b. DIRECTION OF PEDESTRIAN (SW corner to NW corner, etc.)
FROM
TO
47. Pedes-
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (crossing intersection with signal, against signal, diagonally; in roadway playing,
trian
walking, hitchhiking, etc.)
NSN 7540-00-634-4041
STANDARD FORM 91
(2/2004)
Previous edition not usable
Prescribed by GSA-FMR 102-34.295
INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X,
Please read the
MOTOR VEHICLE
items 73 thru 83c are filled on by the operator's supervisor. Section XI thru XIII are filled out
Privacy Act State-
ACCIDENT REPORT
by an accident investigator for bodily injury, fatality,and/or damage exceeding $500.
ment on Page 3
SECTION I - FEDERAL VEHICLE DATA
1. DRIVER'S NAME (Last, first, middle)
2. DRIVER'S LICENSE NO./STATE/LIMITATIONS
DATE OF ACCIDENT
4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS
4b. WORK TELEPHONE NUMBER
5. TAG OR IDENTIFICATION NUMBER
6. EST. REPAIR COST 7. YEAR OF VEHICLE 8. MAKE
9. MODEL
10. SEAT BELTS USED
YES
NO
$
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 NO./
14. DRIVER'S LICENSE NO./STATE/LIMITATIONS
TAX IDENTIFICATION NO.
15. a DRIVER'S WORK ADDRESS
15b. WORK TELEPHONE NUMBER
16a. DRIVER'SHOME 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. DRIVE'S INSURANCE COMPANY NAME AND ADDRESS
23b. POLICY NUMBER
23c. TELEPHONE NUMBER
24. VEHICLE IS
25a. OWNER'S NAME(S) (Last, first, middle)
25b. TELEPHONE NUMBER
CO-OWNED
RENTAL
LEASED
PRIVATELY OWNED
26. OWNER'S ADDRESS(ES)
SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed)
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
A
FED
KILLED
DRIVER
PASSENGER
HELPER
OTHER (2)
INJURED
PEDESTRIAN
35. TRANSPORTED BY
36. TRANSPORTED TO
37. NAME (last, first, middle)
38. SEX
39. DATE OF BIRTH
40. ADDRESS
B
41. MARK "X" IN TWO APPROPRIATE BOXES
43. LOCATION IN VEHICLE
44. FIRST AID GIVEN BY
42. IN WHICH VEHICLE
KILLED
DRIVER
PASSENGER
FED
INJURED
HELPER
PEDESTRIAN
OTHER (2)
45. TRANSPORTED BY
46. TRANSPORTED TO
a. NAME OF STREET OR HIGHWAY
b. DIRECTION OF PEDESTRIAN (SW corner to NW corner, etc.)
FROM
TO
47. Pedes-
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (crossing intersection with signal, against signal, diagonally; in roadway playing,
trian
walking, hitchhiking, etc.)
NSN 7540-00-634-4041
STANDARD FORM 91
(2/2004)
Previous edition not usable
Prescribed by GSA-FMR 102-34.295
SECTION IV - ACCIDENT TIME AND LOCATION (Use section VII if additional space is needed.)
48. DATE OF ACCIDENT 49. PLACE OF ACCIDENT (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 ACCIDENT
AM
PM
52. POINT OF IMPACT
51. INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED
(Check one for each
vehicle)
FED
2
AREA
a. Front
b. R. Front
c.
L. Front
d. Rear
e. R. Rear
f.
L. Rear
g. R. Side
h. L. 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, weather conditions, driver visibility, condition of accident 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 SF 94, Statement of Witness) (Continue in Section VIII.)
54. NAME (Last, first, middle)
55. WORK TELEPHONE NUMBER
56. HOME TELEPHONE NUMBER
A
57. WORK ADDRESS
58. HOME ADDRESS
59. NAME (Last, first, middle)
60. WORK TELEPHONE NUMBER
61. HOME TELEPHONE NUMBER
B
62. WORK ADDRESS
63. HOME ADDRESS
SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)
64a. NAME OF OWNER (Last, first, middle)
64b. WORK 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 ACCIDENT
71b. VIOLATION(S)
STANDARD FORM 91
PAGE 2
(2/2004)
SECTION VIII - EXTRA DETAILS
SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND
PAPER.
PRIVACY ACT STATEMENT
The information on this form is subject to the Privacy Act of 1974 (5 U.S.C. section 552a). Authority to collect the information is Title 40
U.S.C. Section 491 and the title 31 U.S.C. Section 7701. The formation is required by federal Government agencies to administer motor
vehicle programs, including maintaining records on accidents involving privately owned and Federal fleet vehicles,and collecting
accident claims resulting from accidents. Federal employees, and employees under contract, will use the information only in the
performance of their official duties. Routine uses of the collected information may include disclosures to: appropriate Federal, State, or
local agencies or contractors when relevant to civil, criminal, or regulatory investigations or prosecutions; the Office of personnel
Management and the General Accounting Office for program evaluation purposes; a Member of Congress or staff in response to a
request for assistance by the individual of record; another Federal agency, including the Department of Treasury and Justice, or a court
under judicial proceedings; agency Inspectors General in conducting audits; private insurance and the collection agencies (including
agencies under contract to Treasury to collect debt), and to other agency finance offices for federal management and debt collection.
Furnishing the requested information is mandatory, including the Social security Number or Taxpayer's Identification Number(TIN) for
use as a unique identifier to ensure accurate identification for individuals or firms in the system.
SECTION IX - FEDERAL DRIVER CERTIFICATION
I certify that the information on this form (Sections I thru VII) is correct to the best of my knowledge and belief.
72a. NAME AND TITLE OF DRIVER
72b. DRIVER'S SIGNATURE AND DATE
SECTION X - DETAILS OF TRIP DURING WHICH ACCIDENT OCCURRED
73. ORIGIN
74. DESTINATION
75. EXACT PURPOSE OF TRIP
DATE
TIME (Include AM or PM)
DATE
TIME (Include AM or PM)
77. ACCIDENT
76. TRIP BEGAN
OCCURRED
78. AUTHOURITY FOR THE TRIP WAS GIVEN TO THE OPERATOR
79. WAS THERE ANY DEVIATION FROM DIRECT ROUTE?
NO
ORALLY
IN WRITING (Explain)
YES (Explain)
80. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS?
81. DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHER
THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?
YES
NO (Explain)
NO
YES (Explain)
a. DID THIS ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY
82. COMPLETED
b. COMENTS
BY DRIVER'S
YES
SUPERVISOR
NO
83a. NAME AND TITLE OF SUPERVISOR
83b. SUPERVISOR'S SIGNATURE AND DATE
83c. TELEPHONE NUMBER
STANDARD FORM 91
PAGE 3
(2/2004)
SECTION XI - ACCIDENT INVESTIGATION DATA
84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION.
NO
YES (If checked, explain below.)
85. PERSONS INTERVIEWED
NAME
DATE
NAME
DATE
a.
c.
b.
d.
86. ADDITIONAL COMMENTS (Indicate section and item number of each comment).
SECTION XII - ATTACHMENTS
87. LIST ALL ATTACHMENTS TO THIS REPORT
SECTION XIII - COMMENTS/APPROVALS
88. REVIEWING OFFICIAL'S COMMENTS
89. ACCIDENT INVESTIGATOR
90. ACCIDENT REVIEWING OFFICIAL
a. SIGNATURE
b. DATE
a. SIGNATURE
b. DATE
c. NAME (First, middle, last)
c. NAME (First, middle, last)
d. TITLE
d. TITLE
e. OFFICE
e. OFFICE
f. OFFICE TELEPHONE NUMBER
f. OFFICE TELEPHONE NUMBER
AREA CODE
AREA CODE
NUMBER
EXTENSION
NUMBER
EXTENSION
STANDARD FORM 91
PAGE 4
(2/2004)

Download GSA Form SF-91 Motor Vehicle Accident Report

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