Form HSMV 90011S at a glance
What it is: Form HSMV 90011S is the Driver Report of Traffic Crash (Self Report) and the Driver Exchange of Information.
Who signs: Sign on the Signature of Driver Making Report line, and fill in the Date.
Where and when to file: Submit this via email to SelfReportCrashes@flhsmv.gov.
A filled-in Form HSMV 90011S example: a driver reports a crash that damaged only her car
How to fill out Form HSMV 90011S, box by box
The crash: date, time and place
Fill in the Reporting Agency Case Number, the Date of Crash and the Time of Crash, AM or PM.
Fill in the County of Crash (County Code) and the Place or City of Crash (City Code), and check if within city limits.
Fill in the street, road, highway the crash occurred on.
Fill in At Street Address #, Feet or Miles with N, S, E or W, At/From Intersection With Street, Road, Highway, or From Milepost #.
Section One: the first vehicle or non-motorist
In Section One, check Vehicle or Non-Motorist, and fill in the (optional) Email Owner/Driver.
Fill in the Year, Make (Chevy, Ford, Etc.), Vehicle Body Type (Car, Truck. Etc.), Vehicle License Number, State and VIN.
Fill in the Insurance Company and the Insurance Policy Number.
Fill in the Name of Vehicle Owner (Check if same as Driver), the Current Address (Number and Street), City and State and Zip Code.
Fill in the Name of Driver (Take From Driver License)/Non-Motorist, the Current Address (Number and Street), City and State and Zip Code.
Fill in the Driver License Number, State, DL Type, Driver/Non-Motorist Home Phone, Driver/Non-Motorist Business Phone, Sex and Date of Birth.
For each passenger, fill in the Name of Passenger, Current Address (Number and Street), City and State and Zip Code.
Section Two and Section Three
In Section Two and Section Three, check Vehicle or Non-Motorist, and fill in the (optional) Email Owner/Driver.
For additional vehicles or other involved parties, please add additional front pages for this Driver Report of Traffic Crash.
Witnesses
Under Witnesses, fill in (1) Name, Current Address, City and State, Zip Code, and (2) Name, Current Address, City and State, Zip Code.
Signing the report
Sign on the Signature of Driver Making Report line, and fill in the Date.
Sign the report at the bottom of the front page.
Additional comments
Please use this space for comments and for listing any witnesses and/or additional passengers, stating which vehicle the passenger was in.
More rules for Form HSMV 90011S
You must read and comply with the instructions on the back of this form.
If you were told to complete and forward this report to the department, please refer to the following instructions and example.
Keep a copy of this report for your records and for insurance purposes.
Common questions about Form HSMV 90011S
Is there a deadline?
Effective July 1, 2012, Section 316.066(1)(e), Florida Statute, requires that the driver of a vehicle that was in any manner involved in a crash resulting in damage to a vehicle or other property which does not require a law enforcement report shall, within 10 days after the crash, submit a written report of the crash to the department. The report shall be submitted on a form approved by the department.
Where do I file it?
Submit this via email to SelfReportCrashes@flhsmv.gov. Mail the report to: Florida Highway Safety & Motor Vehicles Self Report Crash Team 2900 Apalachee Pkwy, MS 28 Tallahassee, Florida 32399
Sources
[1] Form HSMV 90011S (rev 11/2019), Driver Report of Traffic Crash (Self Report), Florida Department of Highway Safety and Motor Vehicles (the Official source link on this page).
