735-32

OREGON TRAFFIC CRASH AND INSURANCE REPORT

Tear this sheet off your report, read and carefully follow the directions.

ONLY drivers involved in a crash resulting in any of the following MUST file a Crash & Insurance Report:

•

Damage to your vehicle is over $2500

•

Damage to any one person’s property over $2500

•

Injury (No matter how minor)

Any vehicle has damage over $2500 and any vehicle is

•

Death

towed from the scene as a result of damages

Oregon law requires these reports be filed within 72 hours of the crash. If you are not able to file within the 72 hours, submit it

as soon as possible. If you fail to report the crash to DMV, it may result in suspension of your driving privileges. If the police

department files a police report, you are still required to file your own Crash and Insurance Report with DMV. When

required to report, even if you are licensed in another state, or you are not an Oregon resident, you still must file a

report with Oregon DMV. DMV does not determine fault in a crash, but does post the crash to the driving record of those

drivers required to report, unless the vehicle is parked. If you have questions, please call DMV Crash Reporting Unit at

(503) 945-5098.

INSTRUCTIONS

PRINT OR TYPE ALL INFORMATION. (Use black or dark blue ink and press firmly.)

•

Complete both sides of the form.

•

If additional vehicles were involved in the crash, complete the attached Supplemental Report (Form 735-32B), or on a

blank piece of paper, write all the information as requested in Section 4, the “Other Driver” Section.

•

DMV Headquarters will verify the insurance information submitted. Complete the insurance section or a suspension of

your driving privileges may occur.

SECTION 1

DATE, LOCATION AND TIME — Clearly identify the date, location and time of the crash. The correct date, location and time

are critical to processing your report. If you are unsure of the county, contact any local law enforcement agency for assistance.

SECTION 2

Your vehicle is Vehicle #1. Complete ALL fields. Provide Insurance company name (not agent), policy number, and

Vehicle identification number (VIN). Failure to provide complete insurance and vehicle information may result in DMV issuing

Notice of Suspension due to incomplete information.

SECTION 3

Failure to complete this section may result in DMV sending Notice of Suspension for failure to file a report. Principle purpose of

driving and being paid

to drive does not mean driving to reach a destination to perform a service. Property: Includes, but is not

limited to, fixed or real property, landscaping, signs, parked vehicles, and animals.

COMMERCIAL MOTOR VEHICLE OPERATORS: In addition to this report, Oregon Administrative Rule requires that Form

735-9229, Motor Carrier Crash Report, MUST be filed within 30 days of a commercial motor vehicle crash when there is a

FATALITY, INJURY (requiring treatment away from the scene), or when a vehicle is TOWED from the scene because of

disabling damage. Form 735-9229 (attached on back) MUST be submitted with Oregon Traffic Crash and Insurance Report

(Form 735-32) to DMV.

You may now file the Motor Carrier Crash Report at: www.oregontruckingonline.com/cf/MCAD/pubMetaEntry/accidentRpt/

SECTION 4

OTHER VEHICLE (# 2) — Completion of this information will help DMV match all driver's crash reports more efficiently. If

additional vehicles were involved in the crash, complete attached Supplemental Report (Form 735-32B).

SECTION 5

DESCRIPTION AND SIGNATURE — Describe what happened. It is important for you to sign and date the form. Only a family

member may sign and date this form on behalf of a driver when the driver is incapacitated or physically unable to sign. No other

signatures will be accepted.

COMPLETING AND FILING REPORT

HOW TO SUBMIT A REPORT TO DMV:

• Fax to 503-945-5267

• Mail to DMV Crash Reporting Unit 1905 Lana Ave NE, Salem, Oregon 97314

• Deliver to a DMV office

Keep a copy of the report and documentation that shows when you submitted your report to Oregon DMV. Under ORS

802.220(5), DMV is not authorized to provide you with a copy of the report that you file. If submitting by:

• Fax, many fax machines provide the option to generate a fax confirmation report. Save that report.

• DMV Field Office, request and save that receipt.

PURSUANT TO OREGON INSURANCE LAW, AN INSURANCE COMPANY CAN NOT REQUIRE REPAIRS BE MADE TO A

MOTOR VEHICLE BY A PARTICULAR PERSON OR REPAIR SHOP.

735-32 (7-24)

STK# 300009

INSTRUCTIONS

TOTALED VEHICLE NOTICE

DEFINITIONS AND INSTRUCTIONS FOR TOTALED VEHICLES

IF YOUR CRASH HAS RESULTED IN A “TOTALED” VEHICLE, YOU ARE REQUIRED BY LAW TO

FOLLOW APPROPRIATE INSTRUCTIONS IN THIS NOTICE.

DEFINITION OF “TOTALED” VEHICLE

“Totaled Vehicle” or “Totaled” as defined in Oregon law (ORS 801.527) means:

• A vehicle that is declared a total loss by an insurer who is obligated to cover the loss or a vehicle that the insurer

takes possession of or title to.

• A vehicle that has sustained damage that is not covered by an insurer and the estimated cost to repair the vehicle

is equal to at least 80% of the retail market value prior to the damage. “Retail market value” is defined as the

amount shown in publications used by financial institutions (banks or lenders) in this state.

• A vehicle that is stolen, if it is not recovered within 30 days of theft and the loss is not covered by an insurer.

In this situation, you must notify DMV within 60 days of the theft.

FOLLOW THESE INSTRUCTIONS IF YOUR VEHICLE IS TOTALED

If your vehicle is totaled, in addition to completing the crash report, follow the instruction that is applicable to your

case. Either:

1. SURRENDER the title to the insurer if the damage is covered by an insurer who declares the vehicle to be a

“total loss,” and the insurer takes possession of the vehicle; or

2. SURRENDER the title to DMV and apply for salvage title if the damage is covered by an insurer who declares

the vehicle to be a “total loss,” but you keep possession of the vehicle; or

3. SURRENDER the title to DMV and apply for salvage title if the damage was not covered by an insurer and the

estimated cost of repair is at least 80% of the retail market value of the vehicle before the damage; or

4. NOTIFY DMV that your vehicle has been totaled if, for some reason, you are unable to obtain the title for

surrender. You must provide DMV with a signed statement which includes:

• A description of the vehicle which includes the year model, make, plate number and vehicle identification

number.

• A statement indicating the vehicle has been totaled.

• A statement that you are unable to obtain the title and why.

DO NOT SUBMIT THE TITLE WITH THE CRASH REPORT. You can obtain the Application for Salvage

Title (Form 735-229) from any DMV office, by calling

(503) 945-5000, or on-line at www.oregondmv.com.

Application instructions and fee information are on the back of the form 735-229. If you have questions about

salvage titles, call (503) 945-5122.

NOTE: It is a Class A misdemeanor with a penalty of imprisonment and/or fine if you fail to comply with the above

requirements. (ORS 819.012)

735-32N (3-24)

OREGON TRAFFIC CRASH AND INSURANCE REPORT

COMPLETE BOTH SIDES

Complete this form if the traffic crash occurred on a highway or premise open to the public and meets at least one of the reporting

requirements outlined in Section 3. Failure to report when required may result in DMV issuing Notice of Suspension. Call 503-945-5098 for

assistance in completing the report.

Complete ALL fields. Failure to provide complete information may result in DMV issuing Notice of Suspension.

CRASH REF # _________________________________

DMV USE ONLY

TIME OF DAY

ROAD ON WHICH CRASH OCCURRED (Name of street, road or route)

COUNTY

CRASH DATE (MM/DD/YY)

MILE POST

WITHIN

NEAR

FEET

MILES

N S E W

NAME OF NEAREST INTERSECTING ROAD

WITHIN

NEAR

FEET

MILES

N S E W

NAME OF NEAREST CITY / TOWN

TYPE OF CRASH

- The crash involved one or more of the following:

(Mark all that apply)

Fatality

Bicycle

Pedestrian

More than two vehicles

Two vehicles

Motorized Scooter

Motorcycle

ATV / Snowmobile

Train

Personal (assisted)

Parked vehicle

Fixed object / property

Animal

Overturned vehicle

SECTION 1

DRIVER’S LAST NAME

STATEDRIVER’S LICENSE NUMBER

DATE OF BIRTH (MM/DD/YYYY)

GENDER

Other ____________________

mobility device

M F X

Motor Home / RV

FIRST NAME

MIDDLE NAME

ALIR

INS CO

M T W TH F

S SN

DAY OF WEEK

SECTION 2

(YOUR INFORMATION)

DRIVER’S RESIDENCE ADDRESS

CITY STATE ZIP CODE

CHECK BOX

IF ADDRESS

CHANGE

MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE)

CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS

CITY STATE ZIP CODE

SAME

RENTAL?

INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS

CITY STATE ZIP CODE

POLICY NUMBER

VEHICLE IDENTIFICATION NUMBER

STATE

VEHICLE PLATE NUMBER YEAR MAKE & MODEL

IF ADDITIONAL VEHICLES WERE INVOLVED IN THE CRASH, USE ATTACHED SUPPLEMENTAL REPORT (Form 735-32B).

SECTION 3SECTION 4 (OTHER VEHICLE # 2)

Check all

statements

that apply:

Damage to your vehicle was more than $2500.

Damage to property other than a vehicle involved in the crash is over $2500.

Your vehicle was towed from the scene as a result of damages.

You or passengers in your vehicle were injured.

Your vehicle was parked.

The crash occurred while you were driving your employer’s vehicle.

You were driving on your job and being paid for the principal purpose of driving.

You were being paid to drive and/or deliver persons or property.

You were operating a government owned vehicle marked for transporting mail in accordance with government rules.

You were operating an authorized emergency vehicle.

The crash occurred in a work or maintenance zone. ORS 811.230

A police officer came to the scene.

Name of police department: __________________________

City County State Police

You were operating a commercial motor vehicle requiring you to have a commercial driver license.

You were transporting hazardous material.

A citation was issued to you. The citation was: ________________________________________________________

DRIVER’S NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH GENDER

M F

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS

POLICY NUMBER VEHICLE IDENTIFICATION NUMBER STATE VEHICLE PLATE NUMBER YEAR MAKE & MODEL

DESCRIBE WHAT HAPPENED: (IF MORE SPACE IS NEEDED, SUBMIT ADDITIONAL PAGE)

I certify all information given on this report is true and accurate to the best of my knowledge.

SIGNATURE OF PERSON MAKING REPORT

PRINTED NAME OF PERSON MAKING REPORT DAYTIME PHONE # DATE SIGNED

( )

REASON DRIVER IS UNABLE TO SIGN REPORT PHONE NUMBER OF DRIVER

IF NOT DRIVER’S SIGNATURE, STATE RELATIONSHIP

( )

SECTION 5

735-32 (7-24)

COMPLETE THE OTHER SIDE OF THIS PAGE

STK# 300009

DMV COPY

/ /

Reset Form

If this crash involved a pedestrian or

bicyclist, complete the following:

WITNESS INFORMATION:

PEDESTRIAN NAME BICYCLIST NAME

Pedestrian or bicyclist was going:

N S E W

OCCUPANT INJURY AND SAFETY EQUIPMENT INFORMATION

WRITE one of the codes (1–5) in column D

WRITE M, F or X in column A

INJURY CODE FOR OCCUPANTSSAFETY EQUIPMENT CODES

WRITE one of the codes (0–10) in column C

No seat belt available

Seat belt available but NOT used

Seat belt available and in use

Child restraint device available but NOT used

Child restraint device in use

Child restraint device not available

Helmet NOT in use

Helmet in use

Air bag deployed

Air bag available - NOT deployed

Air bag NOT available10

Fatal

Suspected Serious: severe laceration, broken

or distorted limb, crush injury, significant burns,

unconsciousness, paralysis

Suspected Minor: lump, abrasions, bruises,

Possible

minor lacerations

No apparent

ALONG OR ACROSS: (name of street, road or route)

From:

To:

EXAMPLE: (From: NE corner To: SE corner (or) From: East side To: West side, etc.)

Gender and age of pedestrian / bicyclist:

Age: _____M F

GENDER CODE

Extent of pedestrian / bicyclist injury:

A B C D

SEAT

Complaint of Pain

Fatal

Suspected Serious

OCCUPANTS' NAMES

(your vehicle)

SFTY AIR

GENDER AGE INJURY

No apparent injury

POSITION

EQP BAG

Visible injury

(or none noted)

DRIVER

Pedestrian / bicyclist action: (mark one)

FRONT

CENTER

Crossing at intersection or crosswalk

FRONT

RIGHT

Crossing not at intersection or crosswalk

MIDDLE

LEFT

Walking / riding in roadway with traffic

MIDDLE

Walking / riding in roadway against traffic

Standing in roadway

CENTER

MIDDLE

RIGHT

Pushing or working on vehicles in roadway

REAR

LEFT

Other working in road

Playing in road

REAR

CENTER

Hitchhiking

Not in roadway

REAR

RIGHT

Other________________________________

Use only for vehicles with middle row of seats (i.e., vans, SUVs, etc.)

(specify)

Vehicle Damage Diagram

Number each vehicle:

(name of street,

road or route)

FRONT

Show path by:

Show pedestrian/bicyclist by:

Show railroad tracks by:

Show fixed object by:

YOU INTENDED TO...

Go straight ahead

Make right turn

Make left turn

Make “U” turn

Back up

Enter driveway (also

mark left or right turn)

Remain stopped in traffic

Enter parked position

Slow or Stop

Leave driveway (also

mark left or right turn)

Start in traffic lane

Leave parked position

Remain parked

Overtake and pass

YOUR VEHICLE

Passenger car, pickup, van

Military vehicle

Taxicab

Emergency vehicle

Any of the above and trailer

Priv. or public agency transit veh.

Bus

School bus

Other publicly-owned veh.

Motorcycle

Motor Home / RV

Motor–scooter/bike Personal

(assisted) mobility device Truck

tractor & semi trailer Truck/

truck tractor

Other truck combination

Farm tractor/farm equip.

WEATHER CONDITIONS

Clear

Raining

Snowing

Fog

Other

ROAD SURFACE

Dry

Wet

Snowy

Icy

Other

LIGHT CONDITIONS

Daylight

Dawn or dusk

Darkness (lighted)

Darkness (unlighted)

Other

YOUR RESIDENCE

Local resident

(within 25 miles of crash site)

Residing elsewhere in state

Non–resident of this state:

College student

Military

Temporary job

YOU WERE HEADED

North

East

South

West

On: ____________________

(name of street, road or route)

OTHER DRIVER WAS HEADED

North East

South West

On: ____________________

(name of street, road or route)

USE ARROW TO SHOW

FIRST IMPACT (SHADE

IN DAMAGED AREA)

Vehicle towed

Rollover

Under car

Totaled

Unknown

(name of street,

road or route)

(name of street,

road or route)

DATE OF BIRTH:

SUPPLEMENTAL REPORT

OREGON TRAFFIC CRASH

Supplemental for more than two drivers involved in the crash.

Attach this form to your OREGON TRAFFIC CRASH AND INSURANCE REPORT.

TIME OF DAY COUNTY

M T W TH F AM

S SN

DO NOT WRITE

MILE POST

ROAD ON WHICH CRASH OCCURRED (Name of street, road or route )

IN THIS SPACE

INSURANCE COMPANY NAME (NOT AGENCY) POLICY NUMBER

VEHICLE

VEHICLE IDENTIFICATION NUMBER VEHICLE PLATE NUMBER STATE YEAR MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE) DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH GENDER

M F X

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

INSURANCE COMPANY NAME (NOT AGENCY) POLICY NUMBER

VEHICLE

VEHICLE IDENTIFICATION NUMBER VEHICLE PLATE NUMBER STATE YEAR MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE) DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH

GENDER

M F X

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

INSURANCE COMPANY NAME (NOT AGENCY) POLICY NUMBER

VEHICLE

VEHICLE IDENTIFICATION NUMBER VEHICLE PLATE NUMBER STATE YEAR MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE) DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH GENDER

M F X

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

INSURANCE COMPANY NAME (NOT AGENCY) POLICY NUMBER

VEHICLE

VEHICLE IDENTIFICATION NUMBER VEHICLE PLATE NUMBER STATE YEAR MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE) DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH GENDER

M F X

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

INSURANCE COMPANY NAME (NOT AGENCY) POLICY NUMBER

VEHICLE

VEHICLE IDENTIFICATION NUMBER VEHICLE PLATE NUMBER STATE YEAR MAKE & MODEL

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE) DRIVER’S LICENSE NUMBER STATE DATE OF BIRTH GENDER

M F X

DRIVER’S ADDRESS CITY STATE ZIP CODE

VEHICLE OWNER’S NAME AND ADDRESS CITY STATE ZIP CODE

SAME

735-32B (7-23)

SUPPLEMENTAL REPORT – USE IF MORE THAN TWO VEHICLES

DAY OF WEEK

CRASH DATE (MM/DD/YY)

/ /

MOTOR CARRIER CRASH REPORT

(For CMV Drivers Only)

CRASH ANALYSIS & REPORTING UNIT OREGON

DEPARTMENT OF TRANSPORTATION

POLICY, DATA & ANALYSIS DIVISION

555 13th ST NE STE 2

SALEM OR 97301

EMAIL [email protected]

TELEPHONE 503-986-3507

FAX 503-986-3592

INSTRUCTIONS: IF YOU CHECKED A BOX UNDER THE QUALIFYING VEHICLE COLUMN AND A BOX UNDER THE CRITERIA COLUMN, COMPLETE

THE MOTOR CARRIER CRASH REPORT AND SUBMIT TO THE ADDRESS SHOWN ABOVE. IF YOU HAVE ANY QUESTIONS REGARDING FILLING

OUT THE MOTOR CARRIER CRASH REPORT, PLEASE CALL (503) 986-3507. www.oregontruckingonline.com/cf/MCAD/pubMetaEntry/accidentRpt/

QUALIFYING VEHICLE

COMMERCIAL TRUCK (GVWR OVER 10,000 LBS OR ACTUAL WT

AT TIME OF CRASH EVEN IF GVWR IS SET UNDER 10,000 LBS )

HAZARDOUS MATERIAL PLACARD

COMMERCIAL BUS (DESIGNED FOR 8 OR MORE PASSENGERS)

FARM TRUCK INTERSTATE (OVER 10,000 LBS.)

FARM TRUCK FOR-HIRE (4 OR MORE AXLES)

FARM TRUCK TOWING TRIPLE TRAILERS

FARM TRUCK (OVER 80,000 LBS.)

CRITERIA

ANY PERSON SUSTAINING A FATALITY (WITHIN 30 DAYS OF THE

CRASH)

ANY PERSON SUSTAINING INJURIES REQUIRING TREATMENT AWAY

FROM THE SCENE

ANY VEHICLE INCURRING DISABLING DAMAGE REQUIRING

REMOVAL FROM THE SCENE BY A TOW TRUCK OR ANOTHER

MOTOR VEHICLE

MOTOR CARRIER NAME

US DOT NUMBER

AUTHORITY/FILE NUMBER

ADDRESS CITY STATE ZIP CODE

DRIVER INFORMATION

DRIVER NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH

CDL / DL NUMBER STATE EXPIRATION DATE OF MEDICAL CERTIFICATELICENSE CLASS

LENGTH OF EMPLOYMENT

YEARS MONTHS

MDA B C

COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE CRASH.

AT TIME OF THE CRASH, TOTAL HOURS

DRIVING SINCE LAST OFF-DUTY PERIOD.

TOTAL HOURS ON DUTY DURING THE PREVIOUS

(FILL OUT ONE ONLY, BASED ON TIME DOCUMENTS)

7 CONSECUTIVE DAYS ____________

8 CONSECUTIVE DAYS ____________

DOES YOUR DRIVER HAVE A MEDICAL WAIVER

YES NO

TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)

DRIVER INJURY INFORMATION

RELIEF DRIVER INJUREDRELIEF DRIVER KILLED TOTAL NUMBER OF PASSENGERSYOUR DRIVER INJURED

_____KILLED _____ INJURED

YOUR DRIVER KILLED

YES

YES NO YES NO YES NO

OTHER DRIVER INJURY INFORMATION

TOTAL NUMBER OF PEDESTRIANS

_____KILLED _____ INJURED

TOTAL NUMBER OF BICYCLISTS

_____KILLED _____ INJURED

OTHER MOTOR CARRIER INFORMATION

(IF 2 OR MORE MOTOR CARRIERS WERE INVOLVED)

MOTOR CARRIER NAME

VEHICLE LICENSE # AND STATE

DRIVER'S NAME

DRIVER'S LICENSE # AND STATE

MOTOR CARRIER VEHICLE INFORMATION

YEAR MAKE UNIT NUMBER LICENSE PLATE # & STATE - TRUCK/TRACTOR/BUS TOTAL NO. OF AXLES

INCLUDING TRAILERS

TRACTOR TYPE (SELECT APPROPRIATE TYPE)

Triples (tractor with 3 trailers

Triples (truck with 2 trailers)

Straight truck-full trailer

Doubles (any)

Standard

Tractor/Semi Trailer

Straight Truck

Saddlemount

Heavy Haul

Bus/Van (8 or more

passenger capacity)

Auto/Pickup

TOTAL NUMBER OF OTHER DRIVERS

_____KILLED _____ INJURED

TOTAL NUMBER OF OTHER PASSENGERS

_____KILLED _____ INJURED

735-9229 (7-24)

COMPLETE REVERSE SIDE

SUPPLEMENTAL – MOTOR CARRIER CRASH REPORT

TRAILER TYPE (CHECK ONE)

VAN FLATBED TANKER CONTAINER POLE/LOG DUMP BELLY-DUMP CAR CARRIER LIVESTOCK

MOBILE HOME TOTER PASSENGER DROP-BOX GARBAGE BULK-HOPPER

MIXER

WRECKER FIXED LOAD HEAVY HAUL UTILITY

COMMODITY INFORMATION

COMMODITY BEING TRANSPORTED AT TIME OF CRASH

WAS A HAZARDOUS COMMODITY BEING HAULED

YES NO

WAS HAZARDOUS MATERIAL RELEASED FROM

THE VEHICLE CARGO(NOT A FUEL RELEASE)

YES NO

HAZARD CLASS

CRASH INFORMATION

LOCATION OF CRASH (NEAREST CITY OR TOWN) HIGHWAY AND MILEPOINT/STREET/COUNTY ROAD DIRECTION OF YOUR VEHICLE (CHECK)

N S E W

DATE OF CRASH

TIME

DAY OF THE WEEK (CHECK ONE)

MON TUES WED THU FRI SAT SUN

CONDITIONS AT TIME OF CRASH

WEATHER

(CHECK ONE)

1. CLEAR 2. RAIN 3. SNOW

4. CLOUDY 5. SLEET 6. FOG 7. OTHER

ROAD SURFACE

(CHECK ONE)

1. DRY 2. WET 3. SNOWY

4. ICY 5. OTHER

LIGHT CONDITION

(CHECK ONE)

1. DAY 2. DAWN 3. DUSK

4. ARTIFICIAL LIGHTS

5. DARK 6. OTHER

DESCRIBE WHAT HAPPENED BY CHECKING ALL BOXES THAT APPLY. YOUR VEHICLE IS ALWAYS NO.1. IF OTHER VEHICLES WERE INVOLVED, COMPLETE

COLUMNS 2 & 3 TO CORRESPOND TO THE ACTIONS OF THE SAME NUMBERED VEHICLES LISTED ABOVE UNDER "OTHER DRIVER INFORMATION".

VEHICLES

1 2 3

ACTION VEHICLES

1 2 3

ACTION VEHICLES

1 2 3

ACTION

SLOWING - STOPPING

STOPPED

REAR-END

BACKING

MAKING RIGHT TURN

MAKING LEFT TURN

MAKING U TURN

PROCEEDING STRAIGHT

INTERSECTION

ENTERING TRAFFIC

(FROM SHOULDER,

MEDIAN, PARKING STRIP OR PRIVATE DRIVE)

PASSING

CHANGING LANES

SIDESWIPE

HEAD-ON

SKIDDING

VEHICLE OUT OF CONTROL

ROLL-AWAY

CONTROLLED RR CROSSING

UNCONTROLLED RR CROSSING

RAN OFF ROAD

JACKKNIFE

OVERTURN

SEPARATION OF UNITS

FIRE

EXPLOSION

CARGO SHIFT

CARGO SPILL (HAZARDOUS)

CARGO SPILL (NON-HAZARDOUS)

OTHER (DEER, GUARDRAIL, ETC)

DID YOUR VEHICLE STRIKE A PARKED VEHICLE WAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE

YES NO YES NO

DESCRIPTION OF CRASH (BY CARRIER OR DRIVER)

NAME AND TITLE OF PERSON SIGNING REPORT TELEPHONE NUMBER(S)

SIGNATURE I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE

DATE

SADDLEMOUNT