daves accident report front - mn
TRANSCRIPT
STATE OF MINNESOTA RISK MANAGEMENT DIVISION – P&C CLAIMS UNIT 310 Centennial Office Building 658 Cedar St. St. Paul, MN. 55155 Phone 651-201-2592 www.admin.state.mn.us/risk Providing the best value in government administrative services.
FAX To: Gallagher Bassett From:
Fax: 1-800-748-6159 Pages:
Phone: 1-866-489-5797 Date:
Email: [email protected] cc:
Re:
Please use this form to email or fax the Motor Vehicle Accident Report to Gallagher Bassett Services Inc at the email address or fax number listed above. If you are reporting an Auto Physical Damage claim, (damage to a state auto,) please email the information to the Risk Management Division (RMD) at [email protected] or by fax at 651-297-7715. If there is damage to the state car and damage and injuries to others then you will need to fax this report twice. Once to Gallagher Bassett and once to the RMD. Comments: Regarding New Claim For the State of Minnesota. GB Client Number 004276
MINNESOTA MOTOR VEHICLE ACCIDENT REPORTDRIVER’S TRAFFIC ACCIDENT REPORT FOR STATE USE ONLYTIME/PLACE
MYVEHICLE
NUMBER1
VEHICLE
NUMBER2
A
B
C
DATE OFACCIDENT
MONTH DAY YEAR DAY OF WEEK TIME (AM/PM) COUNTY AGENCY LOCATION CODE
NAME OF STREET OR ROAD NUMBER
ON:NAME OF STREET, ROAD NUMBER OR CITYAT INTERSECTION
WITH
STATE AGENCY NAME ADDRESS CITY STATE ZIP CODE TEL. #
DRIVER
VEHICLE
DRIVER’S FULL NAME ADDRESS CITY STATE ZIP CODE TEL. # INJURY
DRIVER’S LICENSE NUMBER CLASS STATE OF ISSUE DATE OF BIRTH SEX RESTRAINT EJECT
CODE*
CODE* CODE*
LICENSE PLATE NUMBER YEAR STATE OF ISSUE PARTS OF VEHICLE ESTIMATED COSTOF REPAIRS
MODEL YEAR MAKE UNIT NO. VIN NUMBER OF OCCUPANTS $
TOTAL # OF VEHICLES INVOLVED THE STATE OF MINNESOTA IS SELF-INSURED/THE POLICY IDENTIFICATION NUMBER IS A-1046
DRIVER
VEHICLE
OTHEROWNER
FULL NAME ADDRESS CITY STATE ZIP CODE TEL. #
OTHERDRIVER
FULL NAME ADDRESS CITY STATE ZIP CODE TEL. # INJURY
DRIVER’S LICENSE NUMBER CLASS STATE OF ISSUE DATE OF BIRTH SEX
CODE*
LICENSE PLATE NUMBER YEAR STATE OF ISSUE PARTS OF VEHICLE ESTIMATED COSTOF REPAIRS $
MODEL YEAR MAKE COLOR TYPE (AUTO, TRUCK, TAXI, ETC.) NUMBER OF OCCUPANTS
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 *CO
DES
ON
BAC
K
DIRECTIONS
FILL IN THE BOXES NEXTTO THE ARROW BY EN-TERING THE NUMBER OFTHE ITEM WHICH BESTDESCRIBES THE CIRCUM-STANCES OF THE ACCI-DENT.
IF A QUESTION DOESNOT APPLY, ENTER ADASH ( - ).
IF AN ANSWER IS UN-KNOWN, ENTER AN “X.”
TYPE OF ACCIDENT
10 - RR CROSSING GATES11 - RR CROSSING FLASHING LIGHTS12 - RR CROSSING STOP SIGN13 - RRCROSSINGFLASHERS14 - RR OVERHEAD FLASHERS/GATE15 - RR CROSSBUCK90 - DESCRIBE
NON-COLLISION11 - OVERTURN12 - FIRE/EXPLOSION13 - SUBMERSION90 - OTHER (DESCRIBE)
WORK ZONE NOT MARKED5 - CONSTRUCTION6 - MAINTENANCE7 - UTILITY90 - OTHER (DESCRIBE)
COLLISION WITH A(N)1 - MOTOR VEHICLE ON SAME ROADWAY2 - MOTOR VEHICLE ON SEPARATE ROADWAY3 - PARKED MOTOR VEHICLE4 - TRAIN5 - BICYCLIST6 - PEDESTRIAN7 - DEER8 - OTHER ANIMAL9 - FIXED OBJECT10 - FALLING OBJECT (DESCRIBE)
1 - TRAFFIC SIGNAL2 - OVERHEAD FLASHERS3 - STOP SIGN - ALL APPROACHES4 - STOP SIGN - OTHER5 - YIELD SIGN6 - OFFICER/FLAG PERSON, SCHOOL PATROL7 - SCHOOL BUS STOP ARM8 - SCHOOL SIGN ZONE9 - NO PASSING ZONE
TRAFFIC CONTROL DEVICE
ROAD WORK1 - NONEWORK ZONE MARKED2 - CONSTRUCTION3 - MAINTENANCE4 - UTILITY
1
2
3
4
5
6
7
10
11
8
9
FIXED OBJECT STRUCK0 - NOT APPLICABLE1 - CONSTRUCTION EQUIPMENT2 - TRAFFIC SIGNAL3 - RR CROSSING DEVICE4 - LIGHT POLE5 - UTILITY POLE6 - SIGN STRUCTURE/POST7 - MAILBOXES AND/OR POSTS8 - OTHER POLES, ETC.9 - HYDRANT10 - TREE/SHRUBBERY11 -CRASH CUSHION
12 - MEDIAN SAFETY BARRIER13 - BRIDGE/PIER/GUARDRAIL14 - OTHER GUARDRAIL15 - FENCE (NON-MEDIAN BARRIER)16 - CULVERT/HEAD WALL17 - EMBANKMENT/DITCH/CURB16 - BUILDING/WALL19 - ROCK OUTCROPS20 - PARKING METER90 - OTHER (DESCRIBE)
4 - DARK (STREET LIGHTS ON)5 - DARK (STREET LIGHTS OFF)6 - DARK (NO STREET LIGHTS)90 - OTHER (DESCRIBE)
LIGHT1 - DAYLIGHT2 - DAWN (AM)3 - DUSK (PM)
6 - FOG/SMOG/SMOKE7 - BLOWING SAND/DUST/SNOW8 - SEVERE CROSSWINDS90 - OTHER (DESCRIBE)
WEATHER/ATMOSPHERE1 - CLEAR2 - CLOUDY3 - RAIN4 - SNOW5 - SLEET/HAIL/FREEZING RAIN
5 - MUDDY6 - DEBRIS7 - OILY90 - OTHER (DESCRIBE)
ROAD SURFACE1 - DRY2 - WET3 - SNOW/SLUSH4 - ICE/PACKED SNOW
#1
#2
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.
#1
#2 5
87
6 43
21
CONTINUEREPORT ONOTHER SIDE
1 - GOING STRAIGHT AHEAD/FOLLOWING ROADWAY2 - WRONG WAY INTO OPPOSING TRAFFIC3 - RIGHT TURN ON RED4 - LEFT TURN ON RED5 - MAKING RIGHT TURN6 - MAKING LEFT TURN7 - MAKING U-TURN8 - STARTING FROM PARKED POSITION9 - STARTING IN TRAFFIC10 - SLOWING IN TRAFFIC11 - STOPPED IN TRAFFIC12 - ENTERING PARKED POSITION13 - PARKED LEGALLY13 - PARKED LEGALLY15 - AVOIDED VEHICLE/OBJECT IN ROAD17 - CHANGING LANE18 - OVERTAKING/PASSING19 - MERGING20 - BACKING21 - STALLED
PRE-ACCIDENT ACTIONS/MANEUVERS- BY VEHICLE - - BY PEDESTRIAN - - BY BYCYCLIST -
41 - CROSSING WITH SIGNAL42 - CROSSING AGAINST SIGNAL43 - CROSSING MARKED CROSSWALK44 - CROSSING (NO SIGNAL OR MARKED CROSSWALK)45 - WALK/RUN IN ROAD WITH TRAFFIC46 - WALK/RUN IN ROAD AGAINST TRAFFIC47 - STANDING IN ROAD48 - EMERGING FROM BEHIND PARKED VEHICLE49 - CHILD GETTING OFF SCHOOL BUS50 - GETTING ON/OFF VEHICLE51 - PUSHING/WORKING ON VEHICLE52 - WORKING IN ROADWAY53 - PLAYING IN ROADWAY54 - NOT IN ROADWAY
71 - RIDING WITH TRAFFIC72 - RIDING AGAINST TRAFFIC73 - MAKING RIGHT TURN74 -MAKING LEFT TURN75 - MAKING U-TURN76 - RIDING ACROSS ROAD77 - SLOWING/STOPPING/STARTING
90 - OTHER ACTION (DESCRIBE)
PRE-ACCIDENT DIRECTION OF TRAVEL1 - NORTH2 - NORTHEAST3 - EAST4 - SOUTHEAST5 - SOUTH6 - SOUTHWEST7 - WEST8 - NORTHWEST
WAS THERE A POLICEOFFICER AT THE SCENE?
IF YES, WHAT DEPARTMENT? (NAME OF CITY OR COUNTY) WHAT WAS THE POSTEDSPEED LIMIT AT THE SCENEOF THE ACCIDENT?
CITY
Yes No
- OCCUPANT SEAT POSITION CODES -1 - FRONT LEFT2 - FRONT CENTER3 - FRONT RIGHT4 - SECOND SEAT LEFT5 - SECOND SEAT CENTER6 - SECOND SEAT RIGHT7 - THIRD SEAT LEFT8 - THIRD SEAT CENTER9 - THIRD SEAT RIGHT10 - OUTSIDE OF VEHICLE11 - STOPPED IN TRAFFIC12 - MOTORCYCLE/SNOWMOBILE/BICYCLE DRIVER13 - MOTORCYCLE/SNOWMOBILE/BICYCLE PASSENGER ON UNIT90 - OTHER (DESCRIBE)
- RESTRAINT DEVICE CODES -1 - SEAT BELT NOT INSTALLED2 - SEAT BELT INSTALLED, NOT USED3 - SEAT BELT INSTALLED, USED4 - SEAT BELT INSTALLED, IMPROPERLY USED5 - AUTOMATIC BELT INSTALLED, USED6 - AUTOMATIC BELT INSTALLED, CIRCUMVENTED7 - AIRBAG USED WITH SEATBELT8 - AIRBAG USED WITHOUT SEATBELT9 - CHILD RESTRAINT NOT INSTALLED10 - CHILD RESTRAINT INSTALLED, NOT USED11 - CHILD RESTRAINT INSTALLED, USED12 - CHILD RESTRAINT IMPROPERLY USED13 - HELMET NOT USED14 - HELMET USED90 - OTHER (DESCRIBE)
- EJECTION CODES -0 - NOT APPLICABLE1 - TRAPPED, EXTRICATED2 - PARTIALY EJECTED3 - EJECTED4 - NOT EJECTED
- INJURY CODES -K - KILLEDA - VISIBLE SIGNS OF INJURY, AS BLEEDING WOUND OR DISTORTED MEMBER, OR HAD TO BE CARRIED FROM THE SCENEB - OTHER VISIBLE INJURY, AS BRUISES, ABRASIONS, SWELLING, LIMPING, ETC.C - NO VISIBLE INJURY BUT COMPLAINT OF PAIN OR MOMENTARY UNCONCIOUSNESSN - NO INDICATION OF INJURYX - UNKNOWN
PASS
VEH
1
DRIVER: Were you on work status? YESNO *CODES ARE ABOVE ON THIS PAGE
PASS
VEH
2
1. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*
2. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*
1. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*
2. NAME CITY STATE AGE SEX SEAT* RESTRAINT* EJECTION* INJURY*
DESCRIBE ACCIDENT IN SUFFICIENT DETAIL TO DISCLOSE CAUSES. This is a confidential report for department use only.
DIAGRAM WHAT HAPPENEDINDICATE NORTH
BY ARROW
NAME ADDRESS PHONE
WIT
NESS
ES
NAME ADDRESS PHONE
NAME ADDRESS PHONE
SIGNA
TURE
S EMPLOYEE’S SIGNATURE WORK ADDRESS PHONE
SAFETY OFFICERS SIGNATURE (OPTIONAL) WORK ADDRESS PHONE
SUPERVISOR’S NAME WORK ADDRESS PHONE
CHECK IF PHOTOS WERE TAKEN BY WHOM?
(JULY 2010)
Please Note: if completing this form electronically, please sketch diagram on separate piece of paper, scan it, and email it along with this form.
Describe accident: