The Minnesota Accident Report Form is a document that must be completed following any motor vehicle accident in the state of Minnesota. The form requires information about both drivers involved in the crash, as well as details about the accident itself. Drivers are responsible for completing and submitting the form to the appropriate authorities. Failing to do so may result in fines or other penalties. Completing the form correctly is essential in order to ensure that all necessary information is collected following an accident.
The following are some specifics about minnesota accident report. It is suggested that you read this info before you start fiddling with the PDF.
| Question | Answer |
|---|---|
| Form Name | Minnesota Accident Report |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | minnesota motor vehicle crash report online, mn state patrol accident report, mn motor vehicle crash report, mn crash report form |
MINNESOTA MOTOR VEHICLE ACCIDENT REPORT
PS 32001 - 08
The information on this report is used to help build safer roads.
Every driver in a crash involving $1,000 or more in property damage, or injury or death, MUST COMPLETE this form and send it to Driver and Vehicle Services within 10 days.
Failure to provide this information is a misdemeanor under Minnesota Statute 169.09, subdivision 7. See reverse side for address and for data privacy information.
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DRIVER’S TRAFFIC ACCIDENT REPORT |
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DO NOT DETACH |
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DATE OF |
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NAME OF CITY OR TOWNSHIP |
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ACCIDENT |
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ACCIDENT OCCURRED |
LOCATION OF ACCIDENT: |
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(Choose only one box below |
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and proceed to the right) |
ON: |
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AT: |
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AT INTERSECTION |
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(Street Name or Road Number) |
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LOCATION OF ACCIDENT: |
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DISTANCE |
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DIRECTION |
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MILES |
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NOT AT INTERSECTION |
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(Street Name or Road Number) |
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(Number) |
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(Street Name or Road Number) |
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IN PARKING LOT |
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D DRIVER’S FULL NAME |
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DRIVER’S LICENSE NUMBER |
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VE
E R
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LICENSE PLATE NUMBER |
YEAR |
STATE OF ISSUE |
PARTS OF VEHICLE DAMAGED |
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ESTIMATE COST TO REPAIR |
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TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.) |
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# OF OCCUPANTS |
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IGIVE FULL LIABILITY INSURANCE INFORMATION OR IT WILL BE ASSUMED YOU DID NOT HAVE INSURANCE
N
SPLEASE NAME OF INSURANCE COMPANY (NOT AGENCY)
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COPY |
Automobile Insurance |
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POLICY NUMBER |
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Policy Period: from |
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POLICY |
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Name of Policy Holder |
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Your Signature X |
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FULL NAME |
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CODE* |
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DRIVER |
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DRIVER’S LICENSE NUMBER |
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LICENSE PLATE NUMBER |
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TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.) |
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IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATTACH |
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*SEE CODES ON REVERSE SIDE*
ENTER NUMBER FOR CORRECT RESPONSE IN EACH BOX BELOW
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TYPE ACCIDENT |
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COLLISION WITH A(N) |
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COLLISION WITH FIXED OBJECT |
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1- MOTOR VEHICLE |
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8- DEER |
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21- CONSTRUCTION EQUIPMENT |
29- HYDRANT |
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37- EMBANKMENT/DITCH/CURB |
51- OVERTURN/ROLLOVER |
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2- PARKED MOTOR VEHICLE |
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9- OTHER ANIMAL |
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22- TRAFFIC SIGNAL |
30- TREE/SHRUBBERY |
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38- BUILDING/WALL |
52- SUBMERSION |
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3- ROADWAY EQUIPMENT - SNOWPLOW |
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23- RR CROSSING DEVICE |
31- BRIDGE PIERS |
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39- ROCK OUTCROPS |
53- FIRE/EXPLOSION |
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4- ROADWAY EQUIPMENT - OTHER |
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12- COLLISION WITH OTHER |
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24- LIGHT POLE |
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32- MEDIAN SAFETY BARRIER |
40- PARKING METER |
54- JACKKNIFE |
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5- TRAIN |
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TYPE OF |
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25- UTILITY POLE |
33- CRASH CUSHION |
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41- OTHER FIXED OBJECT |
55- LOSS/SPILLAGE |
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6- PEDALCYCLE, BIKE, ETC. |
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13- OTHER COLLISION TYPE |
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26- SIGN STRUCTURE |
34- GUARDRAIL |
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42- UNKNOWN FIXED OBJECT |
56- LOSS/SPILLAGE HAZ MAT |
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7- PEDESTRIAN |
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27- MAILBOXES |
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35- FENCE |
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64- |
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28- OTHER POLES |
36- CULVERT/HEADWALL |
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65- |
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WORK ZONE (CIRCLE CORRECT RESPONSE) |
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SPEED LIMIT ENTER POSTED SPEED LIMIT ( NOT YOUR TRAVEL SPEED) |
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YES |
NO |
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DID THE CRASH OCCUR IN A WORK ZONE? |
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YES |
NO |
IF YES, WERE WORKERS PRESENT? |
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WEATHER / ATMOSPHERE |
5- SLEET/HAIL/FREEZING RAIN |
8- SEVERE CROSSWINDS |
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1- CLEAR |
3- RAIN |
6- FOG/SMOG/SMOKE |
90- OTHER |
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ROAD SURFACE |
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2- CLOUDY |
4- SNOW |
7- BLOWING SAND/DUST/SNOW |
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1- DRY |
3- SNOW |
5- ICE PACKED SNOW |
7- MUDDY |
9- OILY |
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2- WET |
6- WATER (STANDING/MOVING) |
8- DEBRIS |
90- OTHER |
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LIGHT CONDITION |
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1- DAY LIGHT |
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4- DARK (STREET LIGHTS ON) |
7- DARK (UNKNOWN LIGHTING) |
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TRAFFIC CONTROL DEVICE |
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2- BEFORE SUNRISE (DAWN) |
5- DARK (STREET LIGHTS OFF) |
90- OTHER |
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1- TRAFFIC SIGNAL |
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7- SCHOOL BUS STOP ARM |
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13- RR OVERHEAD FLASHERS |
3- AFTER SUNSET (DUSK) |
6- DARK (NO STREET LIGHTS) |
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2- OVERHEAD FLASHERS |
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8- SCHOOL ZONE SIGN |
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14- RR OVERHEAD FLASHERS/GATE |
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3- STOP SIGN - ALL APPROACHES |
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9- NO PASSING ZONE |
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15- RR SIGN ONLY |
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4- STOP SIGN - NOT ALL APPROACHES |
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10- RR CROSSING GATE |
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(NO LIGHTS, GATES OR STOP SIGN) |
MANNER OF COLLISION |
4- RAN OFF ROAD - LEFT SIDE |
8- HEAD ON |
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5- YIELD SIGN |
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11- RR CROSSING |
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1- REAR END |
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5- RIGHT ANGLE |
9- SIDE SWIPE - OPPOSING DIRECTION |
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6- OFFICER/FLAG PERSON/SCHOOL PATROL |
12- RR CROSSING - STOP SIGN |
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90- OTHER |
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2- SIDESWIPE - SAME DIRECTION |
6- RIGHT TURN |
90- OTHER |
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98- NOT APPLICABLE |
3- LEFT TURN |
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7- RAN OFF ROAD - RIGHT SIDE |
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MY |
VEHICLE |
OTHER |
VEHICLE |
ACTIONS / MANEUVERS PRIOR TO ACCIDENT
BY VEHICLE |
PARKED VEHICLES |
1- GOING STRAIGHT AHEAD |
21- PARKED LEGALLY |
FOLLOWING ROADWAY |
22- PARKED ILLEGALLY |
2- WRONG WAY INTO |
23- VEHICLE STOPPED |
OPPOSING TRAFFIC |
OFF ROADWAY |
3- RIGHT TURN ON RED |
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4- LEFT TURN ON RED |
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5- MAKING RIGHT TURN |
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6- MAKING LEFT TURN |
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7- MAKING |
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8- STARTING FROM PARKED POSITION |
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9- STARTING IN TRAFFIC |
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10- SLOWING IN TRAFFIC |
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11- STOPPED IN TRAFFIC |
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12- ENTERING PARKED POSITION |
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13- AVOID UNIT/OBJECT IN ROAD |
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14- CHANGING LANES |
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15- OVERTAKING/PASSING |
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16- MERGING |
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17- BACKING |
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18- STALLED ON ROADWAY |
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DIRECTION OF TRAVEL PRIOR TO ACCIDENT |
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BY PEDESTRIAN |
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BY BICYCLIST |
1- NORTHBOUND |
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31- CROSSING WITH SIGNAL |
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40- WALKING/RUNNING IN ROAD |
51- RIDING WITH TRAFFIC |
2- NORTH EASTBOUND |
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32- CROSSING AGAINST SIGNAL |
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AGAINST TRAFFIC |
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52- RIDING AGAINST TRAFFIC |
3- EASTBOUND |
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33- DARTING INTO TRAFFIC |
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41- STANDING/LYING IN ROAD |
53- MAKING RIGHT TURN |
4- SOUTH EASTBOUND |
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34- OTHER IMPROPER CROSSING |
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42- EMERGING FROM BEHIND |
54- MAKING LEFT TURN |
5- SOUTHBOUND |
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35- CROSSING IN A MARKED CROSSWALK |
PARKED VEHICLE |
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55- MAKING |
6- SOUTH WESTBOUND |
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36- CROSSING (NO SIGNAL OR CROSSWALK) |
43- CHILD GETTING ON/OFF SCHOOL BUS |
56- RIDING ACROSS ROAD |
7- WESTBOUND |
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N |
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37- FAIL TO YIELD RIGHT OF WAY TO TRAFFIC |
44- PERSON GETTING ON/OFF VEHICLE |
57- SLOWING/STOPPING/STARTING |
8- NORTH WESTBOUND |
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38- INATTENTION/DISTRACTION |
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45- PUSHING/WORKING ON VEHICLE |
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8 |
1 |
2 |
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39- WALKING/RUNNING IN ROAD WITH TRAFFIC |
46- WORKING IN ROADWAY |
90- OTHER |
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W |
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7 |
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3 |
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E |
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47- PLAYING IN ROADWAY |
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6 |
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4 |
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48- NOT IN ROADWAY |
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5 |
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S |
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CONTINUE |
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WAS THERE A POLICE |
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IF YES, WHAT DEPARTMENT (NAME OF CITY, COUNTY OR STATE PATROL) |
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OFFICER AT THE |
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REPORT ON |
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SCENE? |
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OTHER SIDE |
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YES |
NO |
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VEHICLE |
MY |
VEHICLE |
OTHER |
As required by Minnesota Data Privacy Act you are hereby informed that the information requested on this form is collected pursuant to statute to provide statistical data on traffic accidents. The time and place of the accident, names of parties involved and insurance information may be disclosed to any person involved in the accident or to others persons as specified by law. This written report cannot be used against you as evidence in any civil or criminal matter and your version of how the accident happened is confidential.
SEAT |
TYPE |
USE |
AIR BAG |
EJECT |
INJURY |
OCCUPANT SEAT POSITION CODES |
SAFETY EQUIPMENT TYPE |
RESTRAINT DEVICE USED |
SAFETY EQUIPMENT USED |
EJECTION CODES |
INJURY CODES |
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CODES |
CODES |
CODES |
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1- DRIVER |
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1- TRAPPED, EXTRICATED |
K- KILLED |
(INCLUDE MOTORCYCLE DRIVER) |
1- NO SAFETY EQUIP IN PLACE |
1- BELTS NOT USED |
1- |
(BY MECHANICAL MEANS) |
A- INCAPACITATING INJURY |
2- FRONT CENTER |
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2- LAP BELT ONLY USED |
2- |
2- TRAPPED, FREED BY |
B- |
3- FRONT RIGHT |
2- LAP BELT |
3- SHOULDER BELT ONLY USED |
3- |
C- POSSIBLE INJURY |
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4- SECOND ROW SEAT LEFT |
3- SHOULDER BELT |
4- LAP AND SHOULDER BELT USED |
4- NOT |
3- PARTIALLY EJECTED |
N- NO APPARENT INJURY |
5- SECOND ROW SEAT CENTER |
4- LAP & SHOULDER BELT |
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5- NOT |
4- EJECTED |
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6- SECOND ROW SEAT RIGHT |
5- CHILD SAFETY SEAT |
5- CHILD SEAT NOT USED |
6- NOT DEPLOYED- UNKNOWN |
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7- THIRD ROW SEAT LEFT |
6- CHILD BOOSTER SEAT |
6- CHILD SEAT USED IMPROPERLY |
IF SWITCH ON OR OFF |
5- NOT EJECTED OR TRAPPED |
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8- THIRD ROW SEAT CENTER |
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7- CHILD SEAT USED PROPERLY |
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9- THIRD ROW SEAT RIGHT |
98- NOT APPLICABLE |
8- BOOSTER SEAT NOT USED |
90- OTHER DEPLOYMENTS |
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10- OUTSIDE OF VEHICLE |
(MOTORCYCLE, |
9- BOOSTER SEAT USED IMPROPERLY |
98- NOT APPLICABLE |
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11- TRAILING UNIT |
SNOWMOBILE, ECT.) |
10- BOOSTER SEAT USED PROPERLY |
(MOTORCYCLE, |
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12- PICKUP TRUCK BED |
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SNOWMOBILE, ECT.) |
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13- TRUCK CAB SLEEPER SECTION |
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11- HELMET NOT USED |
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14- PASSENGER IN OTHER POSITION |
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12- HELMET USED |
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(INCLUDE MOTORCYCLE PASSENGER) |
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15- PASSENGER IN UNKNOWN POSITION |
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16- FRONT LEFT |
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MY VEHICLE: DRIVER AND PASSENGERS INFORMATION: |
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DRIVER >>>>>>>>>>>>>>>>>> |
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DATE OF BIRTH (OR AGE) |
SEX |
SEAT |
TYPE |
USE |
AIR BAG |
EJECT |
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INJURY |
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PASSENGER NAME |
CITY |
STATE |
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DATE OF BIRTH (OR AGE) |
SEX |
SEAT |
TYPE |
USE |
AIR BAG |
EJECT |
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INJURY |
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PASSENGER NAME |
CITY |
STATE |
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DATE OF BIRTH (OR AGE) |
SEX |
SEAT |
TYPE |
USE |
AIR BAG |
EJECT |
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INJURY |
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PASSENGER NAME |
CITY |
STATE |
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DATE OF BIRTH (OR AGE) |
SEX |
SEAT |
TYPE |
USE |
AIR BAG |
EJECT |
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INJURY |
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DESCRIBE ACCIDENT IN SUFFICIENT DETAIL BELOW TO DISCLOSE CAUSES. |
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INDICATE |
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NORTH |
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DESCRIBE WHAT HAPPENED: |
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DIAGRAM WHAT HAPPENED: |
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BY ARROW |
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DAMAGE TO PROPERTY OTHER THAN VEHICLES: (MAILBOX, FENCE, SIGNPOST, GUARDRAIL, ETC.)
DESCRIBE |
NAME OF |
PROPERTY |
PROPERTY |
DAMAGED: |
OWNER: |
|
|
ESTIMATE COST OF REPAIR
$
SIGN HERE X
SIGNATURE OF PERSON SUBMITTING REPORT IS REQUIRED
ADDRESS |
DATE OF REPORT |
MAIL THIS REPORT TO:
DVS / ACCIDENT RECORDS
445 MINNESOTA STREET, SUITE 181
ST. PAUL, MN