Form Accident Report PDF Details

At the heart of managing and investigating automotive incidents within federal agency operations lies the comprehensive Accident Report Form, specifically the STANDARD FORM 91 (REV. 9/2020). This document serves as a critical tool in compiling detailed information regarding motor vehicle crashes involving federal vehicles. Carefully structured into thirteen sections, this form embarks on capturing a broad spectrum of data ranging from basic federal vehicle data, details pertaining to other vehicles involved, to the nuances of any fatalities or injuries sustained. Operators of the vehicles find themselves responsible for the initial nine sections, detailing everything from the crash's date and specifics about the vehicle damaged to personal driver data and the precise circumstances of the accident. The supervisor's input becomes relevant in Section X, focusing on the trip details and verification if the crash occurred within the employee's scope of duties, adding an extra layer of accountability and detail. Beyond the immediate factual recounting and administrative certification lies the investigative part, Sections XI through XIII, delving into crash investigation data, additional comments, and attachment listings, culminating in a formal review and approval process by the reviewing official and crash investigator. This meticulously outlined document not only complies with the Privacy Act of 1974 but also underscores the mandatory nature of this reporting, driven by a twofold purpose: ensuring accurate record-keeping and facilitating efficient claims processing, thus encapsulating both the immediate and procedural aftermath of federal vehicle incidents.

QuestionAnswer
Form NameForm Accident Report
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesform accident, massachusetts crash, sf 91 2020, sf 91

Form Preview Example

a. NAME OF STREET OR HIGHWAY

MOTOR VEHICLE

Please read the

INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X, items 73

ACCIDENT (CRASH)

Privacy Act

thru 83c are filled out by the operator's supervisor. Section XI thru XIII are filled out by a crash

 

REPORT

Statement on Page 4

investigator for bodily injury, fatality, and/or damage exceeding $500.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I - FEDERAL VEHICLE DATA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

DRIVER'S NAME (Last, First, Middle)

 

 

 

2. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS

3. DATE OF CRASH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4a.

DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS

 

 

4b. TELEPHONE NUMBER

4c. E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

TAG OR IDENTIFICATION NUMBER

6. ESTIMATED 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 NUMBER/ 14. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS TAX IDENTIFICATION NUMBER

15a. DRIVER'S WORK ADDRESS

 

 

 

 

 

 

 

 

15b. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16a. DRIVER'S HOME 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. DRIVER'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 - FATALITY OR INJURED (Use Section VIII if additional space is needed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

NAME (Last, First, Middle)

 

 

 

 

 

 

 

 

28. SEX

 

29. DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

31. MARK "X" IN TWO APPROPRIATE BOXES

 

32. IN WHICH VEHICLE

33. LOCATION IN VEHICLE

 

34. FIRST AID GIVEN BY

 

 

FATALITY

 

DRIVER

PASSENGER

 

FED

 

 

 

 

 

 

 

 

INJURED

 

HELPER

PEDESTRIAN

 

OTHER (2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

42. IN WHICH VEHICLE

43. LOCATION IN VEHICLE

44. FIRST AID GIVEN BY

 

FATALITY

 

DRIVER

PASSENGER

 

FED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURED

 

HELPER

PEDESTRIAN

 

OTHER (2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45.

TRANSPORTED BY

 

46. TRANSPORTED TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. DIRECTION OF PEDESTRIAN (Southwest (SW) corner to Northwest (NW) corner, etc.)

47.FROMTO

PEDESTRIAN c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF CRASH (crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.)

Previous editions are NOT usable

National Stock Number

STANDARD FORM 91 (REV. 9/2020)

 

7540-00-634-4041

Prescribed by GSA - FMR (41 CFR) 102-34.290

 

 

SECTION IV - CRASH TIME AND LOCATION (Use Section VII if additional space is needed)

48. DATE OF CRASH

50. TIME OF CRASH

AM

PM

49.PLACE OF CRASH (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business, residential, open country, etc.); Road description).

51. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED

1. Number the vehicles involved as follows:

Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of travel by arrow.

 

(Example: ---->

1

2 <----)

 

 

2.

Use solid line to show path before crash

 

2

2

 

Broken line after crash - - - -

- - - - - - - -

 

3.

Show pedestrian by

------------------------

>

 

 

4.Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|

5.Give names or numbers of streets or highways

6.Indicate north by arrow in this compass

STANDARD FORM 91 (REV. 9/2020) PAGE 2

52.POINT OF IMPACT (Check one for each vehicle)

FED

2

AREA

FED

2

AREA

FED

2

AREA

FED

2

AREA

FED

2

AREA

FED

2

 

AREA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Front

 

 

b. Right Front

 

 

c. Left Front

 

 

d. Rear

 

 

e. Right Rear

 

 

f.

Left Rear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Right Side

 

 

h. Left 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, driver visibility, condition of crash 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 Standard Form 94 - Statement of Witness) (Continue in Section VIII.)

 

54.

NAME (Last, First, Middle)

55.

TELEPHONE NUMBER

56.

HOME TELEPHONE NUMBER

A

 

 

 

 

 

 

 

 

57.

WORK ADDRESS

 

 

58.

HOME ADDRESS

 

 

 

 

 

 

 

 

 

 

 

59.

NAME (Last, First, Middle)

60.

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.

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 CRASH

71b. VIOLATION(S)

STANDARD FORM 91 (REV. 9/2020) PAGE 3

SECTION VIII - EXTRA DETAILS

SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ON ADDITIONAL SHEETS OF PAPER.

PRIVACY ACT STATEMENT

The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information is required by Federal Government agencies to administer motor vehicle programs, including maintaining records on crashes involving privately owned and Federal fleet vehicles, and collecting crash claims resulting from crashes. 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 Government Accountability 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 the Treasury and the Department of 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

72c. DATE

SECTION X - DETAILS OF TRIP DURING WHICH CRASH OCCURRED

73. ORIGIN

74. DESTINATION

75. EXACT PURPOSE OF TRIP

76. TRIP BEGAN

DATE

TIME (Include AM or PM)

DATE

77.CRASH OCCURRED

TIME (Include AM or PM)

78.

AUTHORITY FOR THE TRIP WAS GIVEN TO THE OPERATOR

79.

WAS THERE ANY DEVIATION FROM DIRECT ROUTE?

 

ORALLY

IN WRITING (Explain)

 

NO

YES (Explain)

 

 

 

 

80.

WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS?

81.

DID THE OPERATOR, WHILE EN ROUTE, ENGAGE IN ANY ACTIVITY OTHER

 

 

 

 

THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?

 

YES

NO (Explain)

 

NO

YES (Explain)

 

 

 

 

 

 

 

 

 

 

82.COMPLETED BY DRIVER'S SUPERVISOR

a. DID THIS CRASH OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY?

YES

b. COMMENTS

 

NO

 

 

 

83a. NAME AND TITLE OF SUPERVISOR

83b. SUPERVISOR'S SIGNATURE

83c. DATE

83d. TELEPHONE NUMBER

STANDARD FORM 91 (REV. 9/2020) PAGE 4

SECTION XI - CRASH INVESTIGATION DATA

84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION?

NO

YES (If checked, explain below.)

 

 

85. PERSONS INTERVIEWED

 

NAME

 

DATE

 

NAME

 

 

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

DATE

89. CRASH INVESTIGATOR

 

90. CRASH 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. TELEPHONE NUMBER

EXTENSION

f. TELEPHONE NUMBER

EXTENSION

g. E-MAIL ADDRESS

g. E-MAIL ADDRESS

STANDARD FORM 91 (REV. 9/2020) PAGE 5

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word document accident report form writing process shown (portion 1)

2. Just after filling in this step, go to the subsequent part and fill in all required details in all these blanks - COOWNED, RENTAL, LEASED, PRIVATELY OWNED, OWNERS ADDRESSES, SECTION III FATALITY OR INJURED, NAME Last First Middle, ADDRESS, SEX, DATE OF BIRTH, MARK X IN TWO APPROPRIATE BOXES, IN WHICH VEHICLE LOCATION IN, FIRST AID GIVEN BY, FATALITY, and DRIVER.

DRIVER, LEASED, and IN WHICH VEHICLE LOCATION IN of word document accident report form

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word document accident report form completion process shown (stage 3)

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Filling out part 4 of word document accident report form

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Part no. 5 in filling out word document accident report form

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