Form PS33201 "Motor Vehicle Crash Report" - Minnesota

What Is Form PS33201?

This is a legal form that was released by the Minnesota Department of Public Safety - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Minnesota Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PS33201 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS33201 "Motor Vehicle Crash Report" - Minnesota

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MINNESOTA
MOTOR VEHICLE CRASH REPORT
Please use BLACK ink
and CAPITAL LETTERS
PS 32001 - 10
The information on this report is used to help build safer roads.
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 169.09, subdivision 7. See reverse side for address and for data privacy information.
dvs.dps.mn.gov
DRIVER’S TRAFFIC CRASH REPORT
DATE OF
MONTH DAY
YEAR
DAY OF WEEK
TIME
TOTAL # OF
COUNTY
NAME OF CITY OR TOWNSHIP
A
CRASH
AM
VEHICLES
CITY
T
INVOLVED
PM
TWP
I
CRASH OCCURRED
LOCATION OF CRASH:
M
(Choose only one box below
E
and proceed to the right)
AT:
ON:
-
(Street Name or Road Number)
(Street Name or Road Number)
AT INTERSECTION
P
LOCATION OF CRASH:
DISTANCE
DIRECTION
N
E
L
MILES
NOT AT INTERSECTION
ON:
S
W
FROM:
FEET
A
(Street Name or Road Number)
(Number)
(Street Name or Road Number)
C
DESCRIBE LOCATION:
IN PARKING LOT
E
DRIVER’S FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
INJURY
D
B
CODE*
M
R
I
Y
V
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
E
V
R
E
H
ADDRESS
CITY
STATE
ZIP CODE
OWNER’S FULL NAME
V
I
E
C
H
L
I
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE DAMAGED
ESTIMATE REPAIR COST
E
C
L
$
E
TYPE (CAR, PICKUP, V AN, SUV, MOTORCYCLE, TRUCK, ETC.)
MAKE
MODEL
YEAR
COLOR
# OF OCCUPANTS
I
GIVE FULL LIABILITY INSURANCE INFORMATION OR IT WILL BE ASSUMED YOU DID NOT HAVE INSURANCE
N
S
PLEASE
NAME OF INSURANCE COMPANY (NOT AGENCY)
U
COPY
R
MONTH
DAY
YEAR
MONTH
DAY
YEAR
FROM
Automobile Insurance
A
POLICY
POLICY NUMBER
Policy Period: from
to
N
C
E
Name of Policy Holder
Address
C
FULL NAME
INJURY
ADDRESS
CITY
STATE
ZIP CODE
OTHER
D
CODE*
R
O
DRIVER
I
T
V
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
H
E
E
R
R
FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
OTHER
V
V
E
OWNER
E
H
I
H
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE DAMAGED
ESTIMATE COST TO REP AIR
C
I
$
L
C
E
L
TYPE (CAR, PICKUP, V AN, SUV, MOTORCYCLE, TRUCK, ETC.)
# OF OCCUPANTS
MAKE
MODEL
YEAR
COLOR
E
IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATT ACH
ENTER NUMBER FOR CORRECT RESPONSE IN EACH BOX BELOW
TYPE CRASH
COLLISION WITH FIXED OBJECT
NON-COLLISION
COLLISION WITH A(N)
21- CONSTRUCTION EQUIPMENT
29- HYDRANT
37- EMBANKMENT/DITCH/CURB
51- OVERTURN/ROLLOVER
1- MOTOR VEHICLE
9- OTHER ANIMAL
38- BUILDING/WALL
22- TRAFFIC SIGNAL
30- TREE/SHRUBBERY
52- SUBMERSION
2- PARKED MOTOR VEHICLE
39- ROCK OUTCROPS
23- RR CROSSING DEVICE
31- BRIDGE PIERS
53- FIRE/EXPLOSION
3- ROADWAY EQUIPMENT - SNOWPLOW
12- COLLISION WITH OTHER
40- PARKING METER
4- ROADWAY EQUIPMENT - OTHER
24- LIGHT POLE
32- MEDIAN SAFETY BARRIER
54- JACKKNIFE
TYPE OF NON-FIXED OBJECT
41- OTHER FIXED OBJECT
55- LOSS/SPILLAGE NON-HAZ MAT
5- TRAIN
25- UTILITY POLE
33- CRASH CUSHION
13- OTHER COLLISION TYPE
26- SIGN STRUCTURE
34- GUARDRAIL
42- UNKNOWN FIXED OBJECT
56- LOSS/SPILLAGE HAZ MAT
6- PEDALCYCLE, BIKE, ETC.
27- MAILBOXES
35- FENCE (NON-MEDIAN BARRIER)
64- NON-COLLISION OF OTHER TYPE
7- PEDESTRIAN
28- OTHER POLES
36- CULVERT/HEADWALL
65- NON-COLLISION OF UNKNOWN TYPE
8- DEER
WORK ZONE (CIRCLE CORRECT RESPONSE)
SPEED LIMIT ENTER POSTED SPEED LIMIT ( NOT YOUR TRAVEL SPEED)
YES NO
DID THE CRASH OCCUR IN A WORK ZONE?
YES NO
IF YES, WERE WORKERS PRESENT?
WEATHER / ATMOSPHERE
5- SLEET/HAIL/FREEZING RAIN
8- SEVERE CROSSWINDS
90- OTHER
1- CLEAR
6- FOG/SMOG/SMOKE
3- RAIN
ROAD SURFACE
2- CLOUDY
4- SNOW
7- BLOWING SAND/DUST/SNOW
7- MUDDY
1- DRY
3- SNOW
5- ICE PACKED SNOW
9- OILY
4-SLUSH
6- WATER (STANDING/MOVING)
8- DEBRIS
90- OTHER
2- WET
LIGHT CONDITION
7- DARK (UNKNOWN LIGHTING)
1- DAY LIGHT
4- DARK (STREET LIGHTS ON)
TRAFFIC CONTROL DEVICE
90- OTHER
2- BEFORE SUNRISE (DAWN)
5- DARK (STREET LIGHTS OFF)
1- TRAFFIC SIGNAL
7- SCHOOL BUS STOP ARM
14- RR OVERHEAD FLASHERS/
3- AFTER SUNSET (DUSK)
6- DARK (NO STREET LIGHTS)
2- OVERHEAD FLASHERS
8- SCHOOL ZONE SIGN
GATE
9- NO PASSING ZONE
3- STOP SIGN - ALL APPROACHES
15- RR SIGN ONLY (NO LIGHTS,
MANNER OF COLLISION
4- RAN OFF ROAD - LEFT SIDE
8- HEAD ON
4- STOP SIGN - NOT ALL APPROACHES
10- RR CROSSING GATE
GATES OR STOP SIGN)
1- REAR END
5- RIGHT ANGLE (”T-BONE”)
9- SIDE SWIPE
5- YIELD SIGN
11- RR CROSSING -FLASHING LIGHTS
2- SIDESWIPE - SAME DIRECTION
6- RIGHT TURN
- OPPOSING DIRECTION
6- OFFICER/FLAG PERSON/SCHOOL
12- RR CROSSING - STOP SIGN
90- OTHER
3- LEFT TURN
7- RAN OFF ROAD - RIGHT SIDE
90- OTHER
PATROL
13- RR OVERHEAD FLASHERS
98- NOT APPLICABLE
ACTIONS / MANEUVERS PRIOR TO CRASH
DIRECTION OF TRAVEL PRIOR TO CRASH
BY VEHICLE
PARKED VEHICLES
BY PEDESTRIAN
BY BICYCLIST
1- NORTHBOUND
41- STANDING/LYING IN ROAD
1- GOING STRAIGHT AHEAD
21- PARKED LEGALLY
31- CROSSING WITH SIGNAL
51- RIDING WITH TRAFFIC
2- NORTH EASTBOUND
22- PARKED ILLEGALLY
32- CROSSING AGAINST SIGNAL
42- EMERGING FROM BEHIND
52- RIDING AGAINST TRAFFIC
FOLLOWING ROADWAY
3- EASTBOUND
2- WRONG WAY INTO
23- VEHICLE STOPPED
33- DARTING INTO TRAFFIC
PARKED VEHICLE
53- MAKING RIGHT TURN
4- SOUTH EASTBOUND
OPPOSING TRAFFIC
OFF ROADWAY
34- OTHER IMPROPER CROSSING
43- CHILD GETTING ON/OFF
54- MAKING LEFT TURN
5- SOUTHBOUND
3- RIGHT TURN ON RED
35- CROSSING IN A MARKED CROSSWALK
SCHOOL BUS
55- MAKING U-TURN
6- SOUTH WESTBOUND
4- LEFT TURN ON RED
36- CROSSING (NO SIGNAL OR CROSSWALK)
44- PERSON GETTING ON/OFF
56- RIDING ACROSS ROAD
7- WESTBOUND
VEHICLE
5- MAKING RIGHT TURN
37- FAIL TO YIELD RIGHT OF WAY TO TRAFFIC
57- SLOWING/STOPPING/
8- NORTH WESTBOUND
38- INATTENTION/DISTRACTION
45- PUSHING/WORKING ON VEHICLE
6- MAKING LEFT TURN
STARTING
N
39- WALKING/RUNNING IN ROAD WITH
46- WORKING IN ROADWAY
7- MAKING U-TURN
8- STARTING FROM PARKED
TRAFFIC
47- PLAYING IN ROADWAY
90- OTHER
1
8
2
POSITION
40- WALKING/RUNNING IN ROAD
48- NOT IN ROADWAY
W
7
3
E
9- STARTING IN TRAFFIC
AGAINST TRAFFIC
6
4
5
10- SLOWING IN TRAFFIC
11- STOPPED IN TRAFFIC
S
12- ENTERING PARKED POSITION
13- AVOID UNIT/OBJECT IN ROAD
14- CHANGING LANES
WAS THERE A POLICE
IF YES, WHAT DEPARTMENT
CONTINUE
(NAME OF CITY, COUNTY OR ST ATE PA TROL)
15- OVERTAKING/PASSING
OFFICER AT THE
REPORT ON
16- MERGING
SCENE?
17- BACKING
OTHER SIDE
YES
NO
18- STALLED ON ROADWAY
MINNESOTA
MOTOR VEHICLE CRASH REPORT
Please use BLACK ink
and CAPITAL LETTERS
PS 32001 - 10
The information on this report is used to help build safer roads.
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 169.09, subdivision 7. See reverse side for address and for data privacy information.
dvs.dps.mn.gov
DRIVER’S TRAFFIC CRASH REPORT
DATE OF
MONTH DAY
YEAR
DAY OF WEEK
TIME
TOTAL # OF
COUNTY
NAME OF CITY OR TOWNSHIP
A
CRASH
AM
VEHICLES
CITY
T
INVOLVED
PM
TWP
I
CRASH OCCURRED
LOCATION OF CRASH:
M
(Choose only one box below
E
and proceed to the right)
AT:
ON:
-
(Street Name or Road Number)
(Street Name or Road Number)
AT INTERSECTION
P
LOCATION OF CRASH:
DISTANCE
DIRECTION
N
E
L
MILES
NOT AT INTERSECTION
ON:
S
W
FROM:
FEET
A
(Street Name or Road Number)
(Number)
(Street Name or Road Number)
C
DESCRIBE LOCATION:
IN PARKING LOT
E
DRIVER’S FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
INJURY
D
B
CODE*
M
R
I
Y
V
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
E
V
R
E
H
ADDRESS
CITY
STATE
ZIP CODE
OWNER’S FULL NAME
V
I
E
C
H
L
I
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE DAMAGED
ESTIMATE REPAIR COST
E
C
L
$
E
TYPE (CAR, PICKUP, V AN, SUV, MOTORCYCLE, TRUCK, ETC.)
MAKE
MODEL
YEAR
COLOR
# OF OCCUPANTS
I
GIVE FULL LIABILITY INSURANCE INFORMATION OR IT WILL BE ASSUMED YOU DID NOT HAVE INSURANCE
N
S
PLEASE
NAME OF INSURANCE COMPANY (NOT AGENCY)
U
COPY
R
MONTH
DAY
YEAR
MONTH
DAY
YEAR
FROM
Automobile Insurance
A
POLICY
POLICY NUMBER
Policy Period: from
to
N
C
E
Name of Policy Holder
Address
C
FULL NAME
INJURY
ADDRESS
CITY
STATE
ZIP CODE
OTHER
D
CODE*
R
O
DRIVER
I
T
V
DRIVER’S LICENSE NUMBER
CLASS
STATE OF ISSUE
DATE OF BIRTH
SEX
H
E
E
R
R
FULL NAME
ADDRESS
CITY
STATE
ZIP CODE
OTHER
V
V
E
OWNER
E
H
I
H
LICENSE PLATE NUMBER
YEAR
STATE OF ISSUE
PARTS OF VEHICLE DAMAGED
ESTIMATE COST TO REP AIR
C
I
$
L
C
E
L
TYPE (CAR, PICKUP, V AN, SUV, MOTORCYCLE, TRUCK, ETC.)
# OF OCCUPANTS
MAKE
MODEL
YEAR
COLOR
E
IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATT ACH
ENTER NUMBER FOR CORRECT RESPONSE IN EACH BOX BELOW
TYPE CRASH
COLLISION WITH FIXED OBJECT
NON-COLLISION
COLLISION WITH A(N)
21- CONSTRUCTION EQUIPMENT
29- HYDRANT
37- EMBANKMENT/DITCH/CURB
51- OVERTURN/ROLLOVER
1- MOTOR VEHICLE
9- OTHER ANIMAL
38- BUILDING/WALL
22- TRAFFIC SIGNAL
30- TREE/SHRUBBERY
52- SUBMERSION
2- PARKED MOTOR VEHICLE
39- ROCK OUTCROPS
23- RR CROSSING DEVICE
31- BRIDGE PIERS
53- FIRE/EXPLOSION
3- ROADWAY EQUIPMENT - SNOWPLOW
12- COLLISION WITH OTHER
40- PARKING METER
4- ROADWAY EQUIPMENT - OTHER
24- LIGHT POLE
32- MEDIAN SAFETY BARRIER
54- JACKKNIFE
TYPE OF NON-FIXED OBJECT
41- OTHER FIXED OBJECT
55- LOSS/SPILLAGE NON-HAZ MAT
5- TRAIN
25- UTILITY POLE
33- CRASH CUSHION
13- OTHER COLLISION TYPE
26- SIGN STRUCTURE
34- GUARDRAIL
42- UNKNOWN FIXED OBJECT
56- LOSS/SPILLAGE HAZ MAT
6- PEDALCYCLE, BIKE, ETC.
27- MAILBOXES
35- FENCE (NON-MEDIAN BARRIER)
64- NON-COLLISION OF OTHER TYPE
7- PEDESTRIAN
28- OTHER POLES
36- CULVERT/HEADWALL
65- NON-COLLISION OF UNKNOWN TYPE
8- DEER
WORK ZONE (CIRCLE CORRECT RESPONSE)
SPEED LIMIT ENTER POSTED SPEED LIMIT ( NOT YOUR TRAVEL SPEED)
YES NO
DID THE CRASH OCCUR IN A WORK ZONE?
YES NO
IF YES, WERE WORKERS PRESENT?
WEATHER / ATMOSPHERE
5- SLEET/HAIL/FREEZING RAIN
8- SEVERE CROSSWINDS
90- OTHER
1- CLEAR
6- FOG/SMOG/SMOKE
3- RAIN
ROAD SURFACE
2- CLOUDY
4- SNOW
7- BLOWING SAND/DUST/SNOW
7- MUDDY
1- DRY
3- SNOW
5- ICE PACKED SNOW
9- OILY
4-SLUSH
6- WATER (STANDING/MOVING)
8- DEBRIS
90- OTHER
2- WET
LIGHT CONDITION
7- DARK (UNKNOWN LIGHTING)
1- DAY LIGHT
4- DARK (STREET LIGHTS ON)
TRAFFIC CONTROL DEVICE
90- OTHER
2- BEFORE SUNRISE (DAWN)
5- DARK (STREET LIGHTS OFF)
1- TRAFFIC SIGNAL
7- SCHOOL BUS STOP ARM
14- RR OVERHEAD FLASHERS/
3- AFTER SUNSET (DUSK)
6- DARK (NO STREET LIGHTS)
2- OVERHEAD FLASHERS
8- SCHOOL ZONE SIGN
GATE
9- NO PASSING ZONE
3- STOP SIGN - ALL APPROACHES
15- RR SIGN ONLY (NO LIGHTS,
MANNER OF COLLISION
4- RAN OFF ROAD - LEFT SIDE
8- HEAD ON
4- STOP SIGN - NOT ALL APPROACHES
10- RR CROSSING GATE
GATES OR STOP SIGN)
1- REAR END
5- RIGHT ANGLE (”T-BONE”)
9- SIDE SWIPE
5- YIELD SIGN
11- RR CROSSING -FLASHING LIGHTS
2- SIDESWIPE - SAME DIRECTION
6- RIGHT TURN
- OPPOSING DIRECTION
6- OFFICER/FLAG PERSON/SCHOOL
12- RR CROSSING - STOP SIGN
90- OTHER
3- LEFT TURN
7- RAN OFF ROAD - RIGHT SIDE
90- OTHER
PATROL
13- RR OVERHEAD FLASHERS
98- NOT APPLICABLE
ACTIONS / MANEUVERS PRIOR TO CRASH
DIRECTION OF TRAVEL PRIOR TO CRASH
BY VEHICLE
PARKED VEHICLES
BY PEDESTRIAN
BY BICYCLIST
1- NORTHBOUND
41- STANDING/LYING IN ROAD
1- GOING STRAIGHT AHEAD
21- PARKED LEGALLY
31- CROSSING WITH SIGNAL
51- RIDING WITH TRAFFIC
2- NORTH EASTBOUND
22- PARKED ILLEGALLY
32- CROSSING AGAINST SIGNAL
42- EMERGING FROM BEHIND
52- RIDING AGAINST TRAFFIC
FOLLOWING ROADWAY
3- EASTBOUND
2- WRONG WAY INTO
23- VEHICLE STOPPED
33- DARTING INTO TRAFFIC
PARKED VEHICLE
53- MAKING RIGHT TURN
4- SOUTH EASTBOUND
OPPOSING TRAFFIC
OFF ROADWAY
34- OTHER IMPROPER CROSSING
43- CHILD GETTING ON/OFF
54- MAKING LEFT TURN
5- SOUTHBOUND
3- RIGHT TURN ON RED
35- CROSSING IN A MARKED CROSSWALK
SCHOOL BUS
55- MAKING U-TURN
6- SOUTH WESTBOUND
4- LEFT TURN ON RED
36- CROSSING (NO SIGNAL OR CROSSWALK)
44- PERSON GETTING ON/OFF
56- RIDING ACROSS ROAD
7- WESTBOUND
VEHICLE
5- MAKING RIGHT TURN
37- FAIL TO YIELD RIGHT OF WAY TO TRAFFIC
57- SLOWING/STOPPING/
8- NORTH WESTBOUND
38- INATTENTION/DISTRACTION
45- PUSHING/WORKING ON VEHICLE
6- MAKING LEFT TURN
STARTING
N
39- WALKING/RUNNING IN ROAD WITH
46- WORKING IN ROADWAY
7- MAKING U-TURN
8- STARTING FROM PARKED
TRAFFIC
47- PLAYING IN ROADWAY
90- OTHER
1
8
2
POSITION
40- WALKING/RUNNING IN ROAD
48- NOT IN ROADWAY
W
7
3
E
9- STARTING IN TRAFFIC
AGAINST TRAFFIC
6
4
5
10- SLOWING IN TRAFFIC
11- STOPPED IN TRAFFIC
S
12- ENTERING PARKED POSITION
13- AVOID UNIT/OBJECT IN ROAD
14- CHANGING LANES
WAS THERE A POLICE
IF YES, WHAT DEPARTMENT
CONTINUE
(NAME OF CITY, COUNTY OR ST ATE PA TROL)
15- OVERTAKING/PASSING
OFFICER AT THE
REPORT ON
16- MERGING
SCENE?
17- BACKING
OTHER SIDE
YES
NO
18- STALLED ON ROADWAY
As required by Minnesota Data Privacy Act you are hereby informed that the information requested on this form is collected pursuant
to statute to provide statistical data on traffic crashes. The time and place of the crash, names of parties involved and insurance
information may be disclosed to any person involved in the crash or to others persons as specified by law. This written report cannot
be used against you as evidence in any civil or criminal matter and your version of how the crash happened is confidential.
SEAT
TYPE
USE
AIR BAG
EJECT
INJURY
OCCUPANT SEAT POSITION CODES
SAFETY EQUIPMENT TYPE
RESTRAINT DEVICE USED
SAFETY EQUIPMENT USED
EJECTION CODES
INJURY CODES
CODES
CODES
CODES
1- DRIVER
1- TRAPPED, EXTRICATED
K- KILLED
(INCLUDE MOTORCYCLE DRIVER)
1- NO SAFETY EQUIP IN PLACE
1- BELTS NOT USED
1- DEPLOYED-FRONT
(BY MECHANICAL MEANS)
A- INCAPACITATING INJURY
2- FRONT CENTER
2- LAP BELT ONLY USED
2- DEPLOYED-SIDE
2- TRAPPED, FREED BY
B- NON-INCAPACITATING INJURY
3- FRONT RIGHT
2- LAP BELT
3- SHOULDER BELT ONLY USED
3- DEPLOYED-FRONT AND SIDE
NON-MECHANICAL MEANS
C- POSSIBLE INJURY
4- SECOND ROW SEAT LEFT
3- SHOULDER BELT
4- LAP AND SHOULDER BELT USED
4- NOT DEPLOYED-SWITCH ON
3- PARTIALLY EJECTED
N- NO APPARENT INJURY
5- SECOND ROW SEAT CENTER
4- LAP & SHOULDER BELT
5- NOT DEPLOYED-SWITCH OFF
4- EJECTED
6- SECOND ROW SEAT RIGHT
5- CHILD SAFETY SEAT
5- CHILD SEAT NOT USED
6- NOT DEPLOYED- UNKNOWN
7- THIRD ROW SEAT LEFT
6- CHILD BOOSTER SEAT
6- CHILD SEAT USED IMPROPERLY
IF SWITCH ON OR OFF
5- NOT EJECTED OR TRAPPED
8- THIRD ROW SEAT CENTER
7- CHILD SEAT USED PROPERLY
9- THIRD ROW SEAT RIGHT
98- NOT APPLICABLE
8- BOOSTER SEAT NOT USED
90- OTHER DEPLOYMENTS
10- OUTSIDE OF VEHICLE
(MOTORCYCLE,
9- BOOSTER SEAT USED IMPROPERLY
98- NOT APPLICABLE
11- TRAILING UNIT
SNOWMOBILE, ECT.)
10- BOOSTER SEAT USED PROPERLY
(MOTORCYCLE,
12- PICKUP TRUCK BED
SNOWMOBILE, ECT.)
13- TRUCK CAB SLEEPER SECTION
11- HELMET NOT USED
14- PASSENGER IN OTHER POSITION
12- HELMET USED
(INCLUDE MOTORCYCLE PASSENGER)
15- PASSENGER IN UNKNOWN POSITION
16- FRONT LEFT (NON-DRIVER)
MY VEHICLE: DRIVER AND PASSENGERS INFORMATION:
DATE OF BIRTH (OR AGE) SEX
SEAT
TYPE
USE
AIR BAG
EJECT
INJURY
DRIVER >>>>>>>>>>>>>>>>>>
DATE OF BIRTH (OR AGE)
PASSENGER NAME
CITY
STATE
SEX
SEAT
TYPE
USE
AIR BAG
EJECT
INJURY
DATE OF BIRTH (OR AGE)
PASSENGER NAME
CITY
STATE
SEX
SEAT
TYPE
USE
AIR BAG
EJECT
INJURY
DATE OF BIRTH (OR AGE)
PASSENGER NAME
CITY
STATE
SEX
SEAT
TYPE
USE
AIR BAG
EJECT
INJURY
DESCRIBE ACCIDENT IN SUFFICIENT DETAIL BELOW TO DISCLOSE CAUSES.
INDICATE
NORTH
DESCRIBE WHAT HAPPENED:
DIAGRAM WHAT HAPPENED:
BY ARROW
DAMAGE TO PROPERTY OTHER THAN VEHICLES:
(MAILBOX, FENCE, SIGNPOST, GUARDRAIL, ETC.)
DESCRIBE
NAME OF
ESTIMATE COST OF REPAIR
PROPERTY
PROPERTY
$
DAMAGED:
OWNER:
X
MAIL THIS REPORT TO:
SIGN HERE
SIGNATURE OF PERSON SUBMITTING REPORT IS REQUIRED
DVS / CRASH RECORDS
445 MINNESOTA STREET , SUITE 181
ADDRESS
DATE OF REPORT
ST. PAUL, MN 55101-5181
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