Minnesota Accident Report PDF Details

The Minnesota Accident Report Form is a document that must be completed following any motor vehicle accident in the state of Minnesota. It requires information about both drivers involved in the crash and details about the accident itself. Drivers are responsible for completing and submitting the form to the appropriate authorities. Failing to do this may result in fines or other penalties. Completing the form correctly is essential to ensure that all necessary information is collected following an accident.

The following are some specifics about the Minnesota accident report. It is suggested that you read this information before you start fiddling with the PDF.

QuestionAnswer
Form Name Minnesota Accident Report
Form Length 2 pages
Fillable? Yes
Fillable fields 80
Avg. time to fill out 10 min
Other names MN crash report form, Minnesota state patrol accident report, MN state patrol accident report, Ninnesota accident report online

Form Preview Example

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.

A

B

C

DRIVER’S TRAFFIC ACCIDENT REPORT

E-form available at www.mndriveinfo.org

 

 

 

DO NOT DETACH

 

 

DATE OF

MONTH

DAY

YEAR

DAY OF WEEK

TIME

 

 

TOTAL # OF

 

COUNTY

 

 

NAME OF CITY OR TOWNSHIP

 

 

 

 

T

 

ACCIDENT

 

 

 

 

 

 

 

 

 

 

AM

VEHICLES

 

 

 

 

 

CITY

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

INVOLVED

 

 

 

 

 

TWP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

ACCIDENT OCCURRED

LOCATION OF ACCIDENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

(Choose only one box below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and proceed to the right)

ON:

 

 

 

 

 

 

 

 

 

 

 

 

 

AT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AT INTERSECTION

 

 

 

 

(Street Name or Road Number)

 

 

 

 

 

 

 

 

(Street Name or Road Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

LOCATION OF ACCIDENT:

 

 

 

 

DISTANCE

 

 

DIRECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILES

N

E

 

 

 

 

 

 

 

A

 

 

NOT AT INTERSECTION

ON:

 

 

 

 

 

 

 

 

 

 

FEET

S

W FROM:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

(Street Name or Road Number)

 

 

 

 

(Number)

 

 

 

 

 

(Street Name or Road Number)

 

 

 

 

 

 

IN PARKING LOT

DESCRIBE LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D DRIVER’S FULL NAME

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

CITY

 

 

STATE

ZIP CODE

 

INJURY

M

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S LICENSE NUMBER

 

 

 

 

 

 

 

 

CLASS

 

 

STATE OF ISSUE

 

DATE OF BIRTH

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VE

E R

H

V

 

OWNER’S FULL NAME

 

 

ADDRESS

 

CITY

 

STATE

ZIP CODE

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

E

 

 

 

 

 

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE PLATE NUMBER

YEAR

STATE OF ISSUE

PARTS OF VEHICLE DAMAGED

 

 

 

ESTIMATE COST TO REPAIR

E

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

$

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.)

MAKE

 

MODEL

YEAR

 

COLOR

 

# OF OCCUPANTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IGIVE FULL LIABILITY INSURANCE INFORMATION OR IT WILL BE ASSUMED YOU DID NOT HAVE INSURANCE

N

SPLEASE NAME OF INSURANCE COMPANY (NOT AGENCY)

 

 

U

COPY

Automobile Insurance

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

YEAR

 

 

 

MONTH

 

DAY

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER

 

 

 

 

 

 

 

 

Policy Period: from

 

 

 

 

 

 

 

 

to

 

 

 

 

 

 

 

 

 

 

A

POLICY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

Name of Policy Holder

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Signature X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

OTHER

FULL NAME

 

 

 

ADDRESS

 

 

 

 

 

CITY

 

 

 

 

STATE

ZIP CODE

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE*

O

 

R

DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

 

DRIVER’S LICENSE NUMBER

 

 

 

 

 

 

CLASS

 

STATE OF ISSUE

 

 

 

DATE OF BIRTH

 

 

 

 

SEX

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

V

OTHER FULL NAME

 

 

 

ADDRESS

 

 

 

 

 

CITY

 

 

 

 

STATE

ZIP CODE

 

 

 

 

HE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

OWNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE PLATE NUMBER

 

YEAR

STATE OF ISSUE

 

PARTS OF VEHICLE DAMAGED

 

 

 

 

 

 

 

 

ESTIMATE COST TO REPAIR

I

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

C

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.)

MAKE

 

 

MODEL

 

 

 

 

YEAR

 

 

COLOR

 

 

# OF OCCUPANTS

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATTACH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*SEE CODES ON REVERSE SIDE*

ENTER NUMBER FOR CORRECT RESPONSE IN EACH BOX BELOW

 

 

 

 

TYPE ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COLLISION WITH A(N)

 

 

 

 

COLLISION WITH FIXED OBJECT

 

 

 

NON-COLLISION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1- MOTOR VEHICLE

 

 

8- DEER

 

21- CONSTRUCTION EQUIPMENT

29- HYDRANT

 

37- EMBANKMENT/DITCH/CURB

51- OVERTURN/ROLLOVER

 

 

 

 

2- PARKED MOTOR VEHICLE

 

9- OTHER ANIMAL

 

22- TRAFFIC SIGNAL

30- TREE/SHRUBBERY

 

38- BUILDING/WALL

52- SUBMERSION

 

 

 

 

3- ROADWAY EQUIPMENT - SNOWPLOW

 

 

 

23- RR CROSSING DEVICE

31- BRIDGE PIERS

 

39- ROCK OUTCROPS

53- FIRE/EXPLOSION

 

 

 

 

4- ROADWAY EQUIPMENT - OTHER

 

12- COLLISION WITH OTHER

 

24- LIGHT POLE

 

32- MEDIAN SAFETY BARRIER

40- PARKING METER

54- JACKKNIFE

 

 

 

 

5- TRAIN

 

 

TYPE OF NON-FIXED OBJECT

 

25- UTILITY POLE

33- CRASH CUSHION

 

41- OTHER FIXED OBJECT

55- LOSS/SPILLAGE NON-HAZ MAT

 

 

 

 

6- PEDALCYCLE, BIKE, ETC.

 

13- OTHER COLLISION TYPE

 

26- SIGN STRUCTURE

34- GUARDRAIL

 

42- UNKNOWN FIXED OBJECT

56- LOSS/SPILLAGE HAZ MAT

 

 

 

 

7- PEDESTRIAN

 

 

 

 

27- MAILBOXES

 

35- FENCE (NON-MEDIAN BARRIER)

 

64- NON-COLLISION OF OTHER TYPE

 

 

 

 

 

 

 

 

 

28- OTHER POLES

36- CULVERT/HEADWALL

 

65- NON-COLLISION OF UNKNOWN TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK ZONE (CIRCLE CORRECT RESPONSE)

 

 

 

 

SPEED LIMIT ENTER POSTED SPEED LIMIT ( NOT YOUR TRAVEL SPEED)

 

YES

NO

 

 

 

 

 

 

 

 

DID THE CRASH OCCUR IN A WORK ZONE?

 

 

 

 

 

 

 

 

 

YES

NO

IF YES, WERE WORKERS PRESENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WEATHER / ATMOSPHERE

5- SLEET/HAIL/FREEZING RAIN

8- SEVERE CROSSWINDS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1- CLEAR

3- RAIN

6- FOG/SMOG/SMOKE

90- OTHER

 

 

 

 

ROAD SURFACE

 

 

 

 

 

 

2- CLOUDY

4- SNOW

7- BLOWING SAND/DUST/SNOW

 

 

 

 

 

1- DRY

3- SNOW

5- ICE PACKED SNOW

7- MUDDY

9- OILY

 

 

 

 

 

 

 

 

2- WET

4-SLUSH

6- WATER (STANDING/MOVING)

8- DEBRIS

90- OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIGHT CONDITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1- DAY LIGHT

 

4- DARK (STREET LIGHTS ON)

7- DARK (UNKNOWN LIGHTING)

 

 

 

 

TRAFFIC CONTROL DEVICE

 

 

 

 

 

2- BEFORE SUNRISE (DAWN)

5- DARK (STREET LIGHTS OFF)

90- OTHER

 

 

 

 

1- TRAFFIC SIGNAL

 

 

7- SCHOOL BUS STOP ARM

 

13- RR OVERHEAD FLASHERS

3- AFTER SUNSET (DUSK)

6- DARK (NO STREET LIGHTS)

 

 

 

 

 

2- OVERHEAD FLASHERS

 

8- SCHOOL ZONE SIGN

 

14- RR OVERHEAD FLASHERS/GATE

 

 

 

 

 

 

 

 

3- STOP SIGN - ALL APPROACHES

 

9- NO PASSING ZONE

 

15- RR SIGN ONLY

 

 

 

 

 

 

 

 

 

4- STOP SIGN - NOT ALL APPROACHES

 

10- RR CROSSING GATE

 

(NO LIGHTS, GATES OR STOP SIGN)

MANNER OF COLLISION

4- RAN OFF ROAD - LEFT SIDE

8- HEAD ON

 

 

 

 

5- YIELD SIGN

 

 

11- RR CROSSING -FLASHING LIGHTS

 

1- REAR END

 

5- RIGHT ANGLE (”T-BONE”)

9- SIDE SWIPE - OPPOSING DIRECTION

 

 

 

 

 

 

 

 

 

 

 

 

6- OFFICER/FLAG PERSON/SCHOOL PATROL

12- RR CROSSING - STOP SIGN

 

90- OTHER

 

2- SIDESWIPE - SAME DIRECTION

6- RIGHT TURN

90- OTHER

 

 

 

 

 

 

 

 

 

98- NOT APPLICABLE

3- LEFT TURN

 

7- RAN OFF ROAD - RIGHT SIDE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

4- LEFT TURN ON RED

 

5- MAKING RIGHT TURN

 

6- MAKING LEFT TURN

 

7- MAKING U-TURN

 

8- STARTING FROM PARKED POSITION

 

9- STARTING IN TRAFFIC

 

10- SLOWING IN TRAFFIC

 

11- STOPPED IN TRAFFIC

 

12- ENTERING PARKED POSITION

 

13- AVOID UNIT/OBJECT IN ROAD

 

14- CHANGING LANES

 

15- OVERTAKING/PASSING

 

16- MERGING

 

17- BACKING

 

18- STALLED ON ROADWAY

 

 

 

 

 

 

 

 

 

 

DIRECTION OF TRAVEL PRIOR TO ACCIDENT

BY PEDESTRIAN

 

 

 

 

BY BICYCLIST

1- NORTHBOUND

 

 

 

 

 

 

 

31- CROSSING WITH SIGNAL

 

40- WALKING/RUNNING IN ROAD

51- RIDING WITH TRAFFIC

2- NORTH EASTBOUND

 

 

 

 

 

 

 

32- CROSSING AGAINST SIGNAL

 

AGAINST TRAFFIC

 

52- RIDING AGAINST TRAFFIC

3- EASTBOUND

 

 

 

 

 

 

 

33- DARTING INTO TRAFFIC

 

41- STANDING/LYING IN ROAD

53- MAKING RIGHT TURN

4- SOUTH EASTBOUND

 

 

 

 

 

 

 

34- OTHER IMPROPER CROSSING

 

42- EMERGING FROM BEHIND

54- MAKING LEFT TURN

5- SOUTHBOUND

 

 

 

 

 

 

 

35- CROSSING IN A MARKED CROSSWALK

PARKED VEHICLE

 

55- MAKING U-TURN

6- SOUTH WESTBOUND

 

 

 

 

 

 

 

36- CROSSING (NO SIGNAL OR CROSSWALK)

43- CHILD GETTING ON/OFF SCHOOL BUS

56- RIDING ACROSS ROAD

7- WESTBOUND

 

 

N

 

 

 

37- FAIL TO YIELD RIGHT OF WAY TO TRAFFIC

44- PERSON GETTING ON/OFF VEHICLE

57- SLOWING/STOPPING/STARTING

8- NORTH WESTBOUND

 

 

 

 

 

38- INATTENTION/DISTRACTION

 

45- PUSHING/WORKING ON VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

8

1

2

 

 

39- WALKING/RUNNING IN ROAD WITH TRAFFIC

46- WORKING IN ROADWAY

90- OTHER

 

 

 

 

 

 

 

 

W

 

7

 

 

3

 

E

 

 

 

47- PLAYING IN ROADWAY

 

 

 

 

 

 

 

 

 

6

 

 

4

 

 

 

 

48- NOT IN ROADWAY

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE

 

WAS THERE A POLICE

 

IF YES, WHAT DEPARTMENT (NAME OF CITY, COUNTY OR STATE PATROL)

 

 

 

 

 

 

 

OFFICER AT THE

 

 

 

 

 

 

 

 

 

 

 

REPORT ON

 

 

 

 

 

 

 

 

 

 

 

 

 

SCENE?

 

 

 

 

 

 

 

 

 

 

 

 

OTHER SIDE

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

CODES

CODES

CODES

 

 

1- DRIVER

 

 

 

1- TRAPPED, EXTRICATED

K- KILLED

(INCLUDE MOTORCYCLE DRIVER)

1- NO SAFETY EQUIP IN PLACE

1- BELTS NOT USED

1- DEPLOYED-FRONT

(BY MECHANICAL MEANS)

A- INCAPACITATING INJURY

2- FRONT CENTER

 

2- LAP BELT ONLY USED

2- DEPLOYED-SIDE

2- TRAPPED, FREED BY

B- NON-INCAPACITATING INJURY

3- FRONT RIGHT

2- LAP BELT

3- SHOULDER BELT ONLY USED

3- DEPLOYED-FRONT AND SIDE

NON-MECHANICAL MEANS

C- POSSIBLE INJURY

4- SECOND ROW SEAT LEFT

3- SHOULDER BELT

4- LAP AND SHOULDER BELT USED

4- NOT DEPLOYED-SWITCH ON

3- PARTIALLY EJECTED

N- NO APPARENT INJURY

5- SECOND ROW SEAT CENTER

4- LAP & SHOULDER BELT

 

5- NOT DEPLOYED-SWITCH OFF

4- EJECTED

 

6- SECOND ROW SEAT RIGHT

5- CHILD SAFETY SEAT

5- CHILD SEAT NOT USED

6- NOT DEPLOYED- UNKNOWN

 

 

7- THIRD ROW SEAT LEFT

6- CHILD BOOSTER SEAT

6- CHILD SEAT USED IMPROPERLY

IF SWITCH ON OR OFF

5- NOT EJECTED OR TRAPPED

 

8- THIRD ROW SEAT CENTER

 

7- CHILD SEAT USED PROPERLY

 

 

 

9- THIRD ROW SEAT RIGHT

98- NOT APPLICABLE

8- BOOSTER SEAT NOT USED

90- OTHER DEPLOYMENTS

 

 

10- OUTSIDE OF VEHICLE

(MOTORCYCLE,

9- BOOSTER SEAT USED IMPROPERLY

98- NOT APPLICABLE

 

 

11- TRAILING UNIT

SNOWMOBILE, ECT.)

10- BOOSTER SEAT USED PROPERLY

(MOTORCYCLE,

 

 

12- PICKUP TRUCK BED

 

 

SNOWMOBILE, ECT.)

 

 

13- TRUCK CAB SLEEPER SECTION

 

11- HELMET NOT USED

 

 

 

14- PASSENGER IN OTHER POSITION

 

12- HELMET USED

 

 

 

(INCLUDE MOTORCYCLE PASSENGER)

 

 

 

 

 

15- PASSENGER IN UNKNOWN POSITION

 

 

 

 

 

16- FRONT LEFT (NON-DRIVER)

 

 

 

 

 

MY VEHICLE: DRIVER AND PASSENGERS INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER >>>>>>>>>>>>>>>>>>

 

DATE OF BIRTH (OR AGE)

SEX

SEAT

TYPE

USE

AIR BAG

EJECT

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASSENGER NAME

CITY

STATE

 

DATE OF BIRTH (OR AGE)

SEX

SEAT

TYPE

USE

AIR BAG

EJECT

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASSENGER NAME

CITY

STATE

 

DATE OF BIRTH (OR AGE)

SEX

SEAT

TYPE

USE

AIR BAG

EJECT

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASSENGER NAME

CITY

STATE

 

DATE OF BIRTH (OR AGE)

SEX

SEAT

TYPE

USE

AIR BAG

EJECT

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE ACCIDENT IN SUFFICIENT DETAIL BELOW TO DISCLOSE CAUSES.

 

 

 

 

 

 

INDICATE

 

 

 

 

 

 

 

NORTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE WHAT HAPPENED:

 

 

DIAGRAM WHAT HAPPENED:

 

 

 

 

 

BY ARROW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 55101-5181

How to Edit Minnesota Accident Report Online for Free

By following these steps, you will have properly completed the Minnesota Accident Report Form, providing valuable data that assist in legal proceedings and insurance matters.
1. Provide Accident Details
Begin by documenting the specifics of the accident, including the exact date, time, and location. Ensure you describe whether the incident occurred at an intersection, in a parking lot, or on a specific section of the road.

mn motor vehicle crash report empty fields to fill out

2. Detail Vehicle Information
Enter all pertinent information regarding your vehicle, such as make, model, year, license plate number, and vehicle identification number (VIN). Repeat this process for the other vehicle(s) involved if applicable.
3. Record Driver Information
For each driver involved, include full name, date of birth, driver’s license number, and contact details.

step 2 to completing mn motor vehicle crash report

4. Accident Diagram
Provide a diagram of the accident. Illustrate the positions and movements of all vehicles involved, indicating the direction each was traveling and where impacts occurred.
5. Describe the Accident
In your own words, give a detailed description of how the accident happened. Include any contributing factors like road conditions, weather, and drivers' actions leading to the accident.

Completing mn motor vehicle crash report stage 3

6. List Damages and Injuries
Document all damages to the vehicles and other property, along with an estimated repair cost. Also, record details of any injuries sustained by drivers, passengers, or pedestrians.
7. Include Insurance Information
Fill out the insurance information for all parties involved, including the insurance company name, policy number, and the policyholder's name.

stage 4 to completing mn motor vehicle crash report

8. Traffic and Environmental Conditions
Note the traffic and environmental conditions during the accident, such as lighting, weather, and road surface conditions.
9. Compliance with Traffic Laws
Indicate any traffic laws that were violated and that contributed to the accident. This includes speeding, failure to yield, running a red light, etc.

mn motor vehicle crash report DAMAGE TO PROPERTY OTHER THAN, NAME OF PROPERTY OWNER, SIGN HERE X, ADDRESS, SIGNATURE OF PERSON SUBMITTING, DATE OF REPORT, ESTIMATE COST OF REPAIR, MAIL THIS REPORT TO, and DVS  ACCIDENT RECORDS  MINNESOTA fields to fill

10. Final Review and Signature
Review the entire form to ensure all information is accurate and complete. Sign and date the form to verify the authenticity of the provided information.

Watch Minnesota Accident Report Video Instruction

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