Form Hsmv 90010 S – Fill Out and Use This PDF

VEHICLE #

Check if Commercial

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

1 Vehicle in Transport

VEHICLE LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

Registration

2 Parked Motor Vehicle

3 Working Vehicle

Hit and Run

YEAR

MAKE

MODEL

STYLE

COLOR

DAMAGE:

EST. AMOUNT

1 No

1 Disabling

4 Minor

2 Yes

2 Functional

88 Unknown

88 Unknown

3 None

INSURANCE COMPANY

INSURANCE POLICY NUMBER

Towed due

VEHICLE REMOVED BY

1 Rotation

to Damage:

2 Owner Request

1 No 2 Yes

3 Driver

77 Other, Explain in Narrative

NAME OF VEHICLE OWNER

(Check if Business)

CURRENT ADDRESS

CITY & STATE

ZIP CODE

TRAILER #

LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

YEAR

MAKE

LENGTH

AXLES

Registration

TRAILER #

LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

YEAR

MAKE

LENGTH

AXLES

Registration

VEHICLE

N

S

E

W Off‐Road Unknown

ON STREET, ROAD, HIGHWAY

AT EST. SPEED POSTED SPEED

TOTAL LANES

TRAVELING

HAZ. MAT. RELEASED

HAZ. MAT PLACARD

HAZ. MAT. NUMBER

HAZ. MAT. CLASS

Area of Initial Impact

Most Damaged Area

1 No

1 No

2 Yes

2 Yes

18

Undercarriage

18

88 Unknown

88 Unknown

19

Overturn

19

MOTOR CARRIER NAME

US DOT NUMBER

20

Windshield

20

21

Trailer

21

MOTOR CARRIER ADDRESS

CITY & STATE

ZIP CODE

PHONE NUMBER

Vehicle Body Type

Trafficway

Commercial Motor Vehicle Configuration

15 Low Speed Vehicle

1 Two‐Way, Not Divided

1 Vehicle 10,000 lbs or less Placarded

8 Truck Tractor/Triple

16 (Sport) Utility Vehicle

2 Two‐Way, Not Divided, with a

for Hazardous Materials

9 Truck more than 10,000 lbs (4,536

17 Cargo Van (10,000 lbs

Continuous Left Turn Lane

2 Single‐Unit Truck (2‐axle and GVWR

kg), Cannot Classify

(4,536 kg) or less)

3 Two‐Way, Divided, Unprotected

more than 10,000 lbs (4,536 kg))

10 Bus/Large Van (seats for 9‐15

18 Motor Coach

(painted >4 feet) Median

3 Single‐Unit Truck (3 or more axles)

occupants, including driver)

1 Passenger Car

19 Other Light Trucks (10,000 lbs

4 Two‐Way, Divided, Positive Median

4 Truck Pulling Trailer(s)

11 Bus (seats for more than 15

2 Passenger Van

(4,536 kg) or less)

Barrier

5 Truck Tractor (bobtail)

occupants, including driver)

3 Pickup

20 Medium/Heavy Trucks (more than

5 One‐Way Trafficway

6 Truck Tractor/Semi‐Trailer

77 Other, Explain in Narrative

7 Motor Home

10,000 lbs (4,536 kg))

88 Unknown

Trailer Type

7 Truck Tractor/Double

88 Unknown

8 Bus

21 Farm Labor Vehicle

1 Single Semi Trailer

11 Motorcycle

TRAILER 1 TRAILER 2

Cargo Body Type

12 Moped

77 Other, Explain in Narrative

2 Tandem Semi Trailer

8 Pole Trailer

13 Intermodal

13 All Terrain Vehicle (ATV)

88 Unknown

3 Tank Trailer

9 Towed Vehicle

3 Van/Enclosed Box

Container Chassis

4 Saddle Mount/Trailer

10 Auto Transport

4 Hopper

14 Vehicle Towing

Comm/Non-Commercial

5 Boat Trailer

77 Other, Explain in

5 Pole‐Trailer

Another Vehicle

1 Interstate Carrier

6 Utility Trailer

Narrative

6 Cargo Tank

15 Not Applicable

2 Intrastate Carrier

7 House Trailer

88 Unknown

1 No Cargo 7 Flatbed

(vehicle 10,000 lbs

3 Not in Commerce/Government

2 Bus

8 Dump

(4,536kg) or less not

9 Concrete Mixer

4 Not in Commerce/Other Truck

Comm

1 10,000 lbs (4,536 kg) or less

displaying HM placard)

Most Harmful Event

Non-Collision

2 10,001‐26,000 lbs (4,536‐11,793 kg)

10 Auto Transport

77 Other, Explain in

GVWR/GCWR

3 More than 26,000 lbs (11,793 kg)

11 Garbage/Refuse

Narrative

1 Overturn/Rollover

4 Not Applicable

12 Log

88 Unknown

2 Fire/Explosion

3 Immersion

Collision with Non-Fixed Object

Collision Fixed Object

29 Cable Barrier

Emergency

4 Jackknife

10 Pedestrian

19 Impact Attenuator/Crash Cushion

30 Concrete Traffic Barrier

5 Cargo/Equipment Loss or Shift

Vehicle Use

11 Pedalcycle

20 Bridge Overhead Structure

31 Other Traffic Barrier

6 Fell/Jumped From Motor Vehicle

12 Railway Vehicle (train, engine)

32 Tree (standing)

Sequence of Events

7 Thrown or Falling Object

13 Animal

21 Bridge Pier or Support

33 Utility Pole/Light Support

22 Bridge Rail

1st

2nd

8 Ran into Water/ Canal

14 Motor Vehicle in Transport

34 Traffic Sign Support

23 Culvert

9 Other Non‐Collision

15 Parked Motor Vehicle

35 Traffic Signal Support

24 Curb

[40‐46 Sequence of Events only]

16 Work Zone/Maintenance

25 Ditch

36 Other Post, Pole, or Support

1 No

40 Equipment Failure (blown tire,

Equipment

26 Embankment

37 Fence

2 Yes

brake failure, etc.)

17 Struck By Falling, Shifting Cargo or

27 Guardrail Face

38 Mailbox

88 Unknown

3rd

4th

41 Separation of Units

Anything Set in Motion by Motor

28 Guardrail End

39 Other Fixed Object (wall,

42 Ran Off Roadway, Right

Vehicle

building, tunnel, etc.)

43 Ran Off Roadway, Left

18 Other Non‐Fixed Object

44 Cross Median

Vehicle Maneuver Action

Traffic Control Device For

Vehicle Defects

45 Cross Centerline

1 Straight Ahead

13 Stopped in Traffic

This Vehicle

Roadway Grade

46 Downhill Runaway

3 Turning Left

14 Slowing

4 Backing

1 Level

Roadway Alignment

15 Negotiating a Curve

8 Flashing Signal

5 Turning Right

12 Suspension

2 Hillcrest

1 Straight

6 Changing Lanes

16 Leaving Traffic Lane

9 Railway Crossing

17 Entering Traffic Lane

1 None

13 Wheels

3 Uphill

8 Parked

Device

2 Curve Right

77 Other, Explain in

1 No Controls

2 Brakes

14 Windows/

4 Downhill

10 Making U‐Turn

10 Person (including

3 Curve Left

Narrative

3 Tires

Windshield

5 Sag (bottom)

11 Overtaking/

4 School Zone Sign/

Flagman, Officer,

88 Unknown

4 Lights (head,

15 Mirrors

Passing

Device

Guard, etc.)

signal, tail)

16 Truck Coupling/

5 Traffic Control

13 Warning Sign

9 Ambulance

Special Function

1 No Special Function

14 Intercity Bus

Signal

77 Other, Explain in

6 Steering

Trailer Hitch/

2 Farm Vehicle

10 Fire Truck

15 Charter/Tour Bus

6 Stop Sign

7 Wipers

Safety Chains

of Motor Vehicle

3 Police

11 Farm Labor Transport

16 Shuttle Bus

Narrative

9 Exhaust System

77 Other, Explain in

7 Yield Sign

88 Unknown

7 Taxi

12 School Bus

17 Farm Labor Bus

10 Body, Doors

Narrative

8 Military

13 Transit/Commuter Bus

88 Unknown

11 Power Train

88 Unknown

VIOLATIONS

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER