Have you recently been involved in an automobile accident in Mississippi? If so, you're likely feeling overwhelmed and confused by the situation. Fortunately, there are resources available to help make the process easier. The Mississippi Department of Public Safety (MDPS) provides a convenient online form to report any motor vehicle accidents on public roads or highways within the state of Mississippi. Completing this required accident report form is crucial for ensuring all parties involved receive fair reimbursement for damages, as well as providing peace of mind that safety standards were followed during your travels throughout the state. Get started now and be sure to read large amounts of information about how best to file your Motor Vehicle Accident Report Form correctly.
| Question | Answer |
|---|---|
| Form Name | Mississippi Accident Report Form |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | mississippi uniform crash report, mississippi accident self report form, mississippi uniform crash report insruction manual 2020, mississippi highway patrol accident reports |
STATE OF MISSISSIPPI UNIFORM CRASH REPORT
Agency Number |
|
|
Agency Case Number |
|||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Page
0 1
of
Agency Name |
G1. County |
|
G2. Status Code
C P U
G3. Reported Date (MM/DD/YYYY)
/ /
G4. Reported Time (2400)
G5. Officer Time
Arrival Time (2400) |
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G6. Vehicles |
G7. Killed |
|
G8. Injured |
||||
|
|
|
|
|
|
|
|
G9. Address Number |
G10. Street Name |
G11. Hwy/County Road # |
G12. Trafficflow Direction |
|||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N |
E |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S |
W |
G13. Int.
Y
N
G14. Distance |
F |
. M
G15. Direction
N E
S W
G16. Intersecting Street Name |
G17. Int. Hwy/County Road # |
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G18. City Name
G19. Latitude
N |
. |
G20. Longitude
W |
. |
G21. First Harmful Event
Crash with OMV in road:
Rear end slow or stop
Rear end turn
Left turn same roadway Left turn cross traffic
Right turn cross traffic
Head on
Sideswipe
Angle
Hit and run
Overturn
Jackknife
Fell from vehicle
Other
Crash of MV in road with:
Pedestrian
Parked Vehicle
Train
Bicyclist
Deer
Animal (other than deer)
Fixed Object |
|
|
|
|
|
Bridge/Culvert |
|
Roadway |
|
None |
|
|
|
|
|
||
Embankment/Ditch/Curb |
Location |
|
|||
Guardrail/Median Barrier |
Median |
|
T - Intersection |
||
|
|
|
Crossover |
||
Tree |
Crash |
Roadside |
Type |
||
|
|||||
Utility pole/light support |
Shoulder |
Driveway |
|||
|
|||||
G22. |
|
|
|||
|
Intersection |
|
|||
Other fixed object |
|
||||
Parking Lot |
|
||||
|
|
||||
Sign Post |
|
Off Ramp |
|||
Signal standard |
Gore |
On Ramp |
|||
|
|
G23. |
|||
|
|
|
Path/Trail |
||
|
|
|
|||
|
|
|
|
||
Building/Other Structure |
|
|
|
RR Xing |
|
|
|
|
|
||
Maint. Equip. - Not Moving |
|
|
|
Traffic Circle/Round |
|
|
|
|
|
||
Maint. Equip. - Moving |
|
|
|
|
|
Other |
|
|
|
Y - Intersection |
|
|
|
|
|
G24. Roadway System
City Street
State Highway
U.S. Highway
County Road
Parking Lot/Private Drive
Interstate
Off Road
State Park
|
Daylight |
|
Dry |
Condition(2) |
|
Condition |
Condition |
|
|||
Wet |
|||||
|
|
|
|||
|
|
Water |
|
||
|
|
|
|
||
LightG25. |
RoadG26. |
Sand/Mud/Dirt/Oil/Gravel |
WeatherG27. |
||
D a w n |
Ice |
||||
|
|
|
|||
|
|
|
|
||
|
|
|
Slush |
|
|
|
Dusk |
|
Snow |
|
|
|
|
|
|
|
Clear |
|
Blown Debris |
Relationship |
|
|
|
|
|
Not Workzone Related |
|
|
Rain |
|
Fog/Smog/Smoke |
|
|
|
|
|
|
|
|
|
|
|
|
Workzone |
Within Construction Zone |
|
Cloudy |
|
Sleet/Hail |
Advance Warning Area |
|
|
|
||||
|
|
|
|
||
|
|
|
|
|
|
|
High winds |
|
Snow |
G28. |
|
|
|
|
WITNESS(ES)
G29. Workzone Type (2)
None
Intermittent or Moving Work Lane Closure
Lane Shift/Crossover
Shoulder/Median Work
Utility
G30. |
First Name |
|
|
MI |
Last Name |
|
|
G31. |
Address |
|
|
|
|
G32. Phone Number |
|
G33. |
City |
|
|
|
G34. |
State |
G35. Zip Code |
|
G36. Sex |
M |
F |
|
|
|
G37. Age |
G38. |
First Name |
|
|
MI |
Last Name |
|
|
|
G39. |
Address |
|
|
|
|
|
G40. Phone Number |
|
|
|
|
|
|
|
|
||
G41. |
City |
|
|
|
G42. |
State |
G43. |
Zip Code |
|
G44. Sex |
M |
F |
|
|
G45. Age |
|
|
|
|
|
|
|
|
|
|
G47. Investigating Officer Name (Please Print) |
|
|
|
G48. Officer Signature |
||
|
G46. |
Badge Number |
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
G49. |
Reviewing Badge Number |
G50. Reviewing Officer Initials |
G51. Photos Taken |
G52. Photographer and Badge # |
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||
Y N
4479140593
MUCR
Diagram/Narrative
Agency Number |
Agency Case Number |
N1. Collision Diagram
Page 0 2 of
North
Arrow
N2. Collision Narrative
1772140596
MUCR
Person/Occupant
V0. Veh. # P0. Person #: Agency Number |
Agency Case Number |
Page
of
P1. Person Type |
|
Driver |
Pedestrian |
Bicyclist |
|
|
Skater |
|
|
|
Other |
Train Engineer |
|
Hit and Run Driver |
|
|
|
||||||||||||
P2. |
License # |
|
|
|
|
|
|
|
|
P3. State |
P4. CDL? |
P5. DOB (MM/DD/YYYY) |
|
|
|
|
|
Shoulder & Lap Belt |
Type |
None |
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
N |
|
|
|
/ |
/ |
|
|
|
|
|
|
|
|
Complaint of Pain |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
|
|
|
|
|
None |
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
StatusDLP12. |
Suspended |
|
Other |
|
SafetyEquip. (2) |
|
|
|
EjectionP24.P23. Injury |
Totally |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Helmet |
|
|
|||||||
P6. |
First Name |
|
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Lap Belt |
|
|
|
Serious |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Valid |
|
Suspended - DUI |
|
|
|
|
|
|
Life Threatening |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Automated Restraint |
|
Killed |
|
||
P7. Address |
|
|
|
|
|
|
|
|
P8. Phone Number |
|
|
|
|
No License |
|
Learner Permit |
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Shoulder Belt |
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Not |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Expired |
|
Improper DL |
|
|
Child Safety Seat |
|
Partially |
||||
P9. |
City |
|
|
|
|
|
|
P10. State |
|
|
P11. |
Zip Code |
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
Y |
P14.Ticket # |
1 |
|
|
|
|
|
|
Offense |
1 |
|
|
|
|
|
|
|
|
|
|
|
Extricated |
N |
|
|
Y |
|
|
P13.Cited |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
White |
|
|
|
Hispanic |
|
|||||
P |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
F |
|
|
|
||||||
|
N |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M |
|
|
|
|
|
|
|
|
2 |
|
|
|
|
|
|
P15. |
2 |
|
|
|
|
|
|
|
|
|
|
Race |
|
|
|
|
|
|
|
Xport |
Not Transported |
Police |
Hearse |
|
|
|
|
|
|
|
|
|
|
|
|
|
Black |
|
|
|
Other |
|
|||||||
|
|
|
|
|
|
|
P18. Medical |
|
|
|
|
|
|
|
|
|
|
||||||||||||
Condition |
|
|
|
|
|
|
|
|
P17. EMS |
|
|
|
|
|
|
|
|
|
|
AirbagPosition |
|
|
|
|
|
|
|
||
EMS |
|
|
|
Private Vehicle |
|
|
ActionMotorist- |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
P16. |
|
|
|
|
|
|
|
|
Agency Code |
|
|
|
|
|
Facility Code |
|
|
|
|
|
Left |
|
Center |
Right |
|||||
|
No Defects Apparent |
|
Obviously Intoxicated |
|
|
|
Unknown |
|
|
|
|
Pushing vehicle |
|
|
|
Deployed - Front |
|
Not Deployed |
|||||||||||
|
Unknown |
|
|
|
Physical Impairment |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Deployed - Side |
|
No Airbag |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
Entering/Crossing Roadway |
Approaching/leaving vehicle |
|
|
|
|
||||||||||||
|
Hit and Run |
|
|
|
Affected by Exhaust Fumes |
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Deployed - Both |
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
P19. |
Drinking - Not impaired |
|
Using Drugs - Impaired |
|
P20. Non |
|
Walking/running/playing/cycling |
Playing/working on vehicle |
|
|
Alcohol Test Information |
|
|||||||||||||||||
Drinking - Impaired |
|
Using Drugs - Not Impaired |
|
|
|
|
|
|
|
|
|
|
|
Type |
|
None |
|
|
|
Serum |
|
||||||||
Fell Asleep/Fainted/Fatigue |
|
Pending Lab Results |
|
|
Working |
|
|
|
|
Standing |
|
|
|
Blood |
|
|
|
Urine |
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
No Apparent Improper Driving |
|
|
Made Improper Turn |
|
|
|
|
|
|
|
Not Visible (Dark Clothing) |
|
|
|
Breath |
|
|
|
|
|
||||||||
(3) |
|
|
|
|
|
|
|
|
|
|
Status |
|
Test refused |
|
|
Test given, pending |
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
Circumstance |
Failed to Yield Right of Way |
|
|
Left of Center |
|
|
|
|
|
|
|
|
Operating Defective Equipment |
|
|
|
None given |
|
|
Test given |
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
Result |
|
|
|
|
|
|
|
|||||||||||
Following Too Closely |
|
|
Failure to keep proper lane/Run off road |
|
|
|
Passed Stop Sign |
|
|
|
|
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
Speed Too Fast For Conditions |
|
|
Avoidance |
|
|
|
|
|
|
|
|
Pedestrian Actions |
|
|
|
. |
|
|
|
|
|
|
||||||
Contributing |
Driving Under The Influence |
|
|
Drove on Wrong Side of Road |
|
|
|
|
|
Ran Red Light |
|
|
|
Type |
|
Blood |
|
|
|
Urine |
|
||||||||
Faulty Equipment |
|
|
Illegally Crossing Median |
|
|
|
|
|
|
Visibility Obstructed |
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Drug Test Information |
|
||||
|
Animal on Roadway |
|
|
Fatigued/Asleep |
|
|
|
|
|
|
|
Roadway Defects |
|
|
|
|
None |
|
|
|
Serum |
|
|||||||
P21. |
Exceeded Lawful Speed |
|
|
Improper Lane Change |
|
|
|
|
|
|
Improper Backing |
|
|
Status |
|
None given |
|
|
Test given, pending |
||||||||||
Improper Passing/Overtaking |
|
|
Lying and/or illegally in roadway |
|
|
|
|
See Crash Description |
|
|
|
Test refused |
|
|
Test given |
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
|
|
|
|
O0. Vehicle #: |
|
O1. |
First Name |
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(2) |
|
None |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PositionO6. |
|
|
|
|
Equip.Safety |
|
|
||||
O2. Address |
|
|
O3. |
Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
Sleeper of Truck Cab |
|
|
Lap Belt |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Same as |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
|
|
Automated Restraint |
||||||
Person # |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
|
Shoulder Belt |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
O4. |
City |
|
|
|
|
|
|
O5. |
State |
|
|
|
|
|
|
Riding on Exterior |
|
O7. |
|
Child Safety Seat |
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Unborn Child |
|
|
Towed Vhcl./Trailer |
|
|
|
Helmet |
|
|||||
O8.Sex |
|
O9.Race |
|
|
|
|
O10.Age |
|
|
|
ExtricatedO11. |
|
|
EjectionO12. |
|
InjuryO13.Type |
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
None |
|
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||||||||||
|
M |
|
|
White |
Hispanic |
|
|
|
M |
|
N |
|
|
Not |
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
|
|
Partially |
|
Complaint of Pain |
|
|
|
Deployed - Side |
No Airbag |
|||||
|
F |
|
|
Black |
Other |
|
|
|
|
|
|
Y |
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
|
Deployed - Both |
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
Xport |
Not Transported |
|
Police |
|
|
Hearse |
O16. EMS |
|
|
|
|
|
O17. Medical |
|
|
|
|
|||||
|
|
|
|
|
|
|
O15. |
EMS |
|
|
|
Private Vehicle |
|
|
Agency Code |
|
|
|
|
Facility Code |
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
|
|
|
|
O0. Vehicle #: |
|
O1. |
First Name |
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(2) |
|
None |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PositionO6. |
|
|
|
|
Equip.Safety |
|
|
||||
O2. Address |
|
|
O3. Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
Sleeper of Truck Cab |
|
|
Lap Belt |
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Same as |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
|
|
Automated Restraint |
||||||
Person # |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
|
Shoulder Belt |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
O4. |
City |
|
|
|
|
|
|
O5. |
State |
|
|
|
|
|
|
Riding on Exterior |
|
O7. |
|
Child Safety Seat |
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Unborn Child |
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Towed Vhcl./Trailer |
|
|
|
Helmet |
|
||||||
O8.Sex |
|
RaceO9. |
|
|
|
|
O10.Age |
|
|
|
ExtricatedO11. |
|
|
EjectionO12. |
|
InjuryO13.Type |
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
None |
|
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||||||||||
|
M |
|
|
White |
Hispanic |
|
|
|
M |
|
N |
|
|
Not |
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
F |
|
|
|
|
|
|
|
|
|
Y |
|
|
|
|
|
Partially |
|
Complaint of Pain |
|
|
|
Deployed - Side |
No Airbag |
|||||
|
|
|
Black |
Other |
|
|
|
|
|
|
Y |
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
|
Deployed - Both |
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
0382395460 |
Xport |
Not Transported |
Police |
Hearse |
O16. EMS |
O17. Medical |
O15. |
EMS |
Private Vehicle |
|
Agency Code |
Facility Code |
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
V0. |
Vehicle #: V1. Total Occupants |
Agency Number |
|
Agency Case Number |
|
|
|
|
||||||
|
|
MUCR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
Vehicle |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Owner Information |
|
|
|
|
||
V2. State |
V3. |
Year |
|
V4. |
License Plate Number |
|
|
Same as V12. |
Owner Name |
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
Driver |
|
|
|
|
|
|
V5. |
Make |
|
|
|
|
|
V6. Model Year |
|
|
V13. |
Address |
|
|
|
||||
V7. |
Vehicle Model |
|
|
|
|
V8. |
Vehicle Color |
|
V14. |
City |
|
|
|
|
||||
|
|
|
|
|
|
|
V10. Speed Zone V11. Est. Speed |
V19. No Proof V17. Insurance Company Name |
|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
of Insurance |
|
|
|
|
|
|
V9. Damage: |
|
Heavy |
Light |
None |
|
|
|
|
|
|
|
|
|
|
|
|||
|
Collision w/ Person, |
|
|
|
Collision w/ Fixed Object |
|
|
|||||||||||
|
1 |
2 |
3 |
4 |
|
|
1 |
2 |
3 |
4 |
|
|
1 |
2 |
3 |
4 |
|
|
|
|
|
|
Animal |
|
|
|
|
|
Cargo Loss/Shift |
|
|
|
Attenuator/Cushion |
|
|||
|
|
|
|
Bicyclist |
|
|
|
|
|
Crossover |
|
|
|
|
Bridge Structure |
|
||
EventsofSequence |
|
|
|
Maintenance Equip. |
|
|
|
Equipment Failure |
|
|
|
Culvert |
ActionVehicleV21. |
|||||
|
|
|
Moving Vehicle |
|
|
|
|
Fell/Jump from Vehicle |
|
|
Curb |
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
Parked Vehicle |
|
|
|
|
Fire/Explosion |
|
|
|
|
Ditch |
|
|
||
|
|
|
|
Pedestrian |
|
|
|
|
Immersion |
|
|
|
|
Embankment |
|
|||
|
|
|
|
Train |
|
|
|
|
|
|
Jackknife |
|
|
|
|
Fence |
|
|
|
|
|
|
Slowing Vehicle |
|
|
|
|
Median/Centerline |
|
|
|
Guardrail |
|
||||
|
|
|
|
Stopped Vehicle in Road |
|
|
|
Thrown/Falling Object |
|
|
Mailbox |
|
||||||
V20. |
|
|
|
|
|
|
|
|
|
|
Off roadway/Left |
|
|
|
Median Barrier |
|
||
|
|
|
|
|
|
|
|
|
|
Off roadway/Right |
|
|
|
Post/Pole/Support |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
Overturn/Rollover |
|
|
|
Tree |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Unit Separation |
|
|
|
|
Other Fixed Object |
|
|
|
|
|
|
|
|
|
|
|
|
|
Over Correcting/Steering |
|
|
|
|
|
||
ConfigurationVehicleV22. |
|
Passenger Car |
|
School Bus |
|
Train |
ContactInitialV23. |
|
|
|
|
|
|
TravelofDirectionV24. |
||||
|
Light Truck |
|
|
|
|
|
|
|
|
|
|
|
|
Under |
||||
|
|
|
|
|
Truck/Trailer |
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
Stationwagon/Van |
|
|
Emergency Veh. |
|
|
|
|
|
Overturn |
|
||||||
|
|
SUV |
|
|
|
Farm Tractor |
|
Commercial Bus |
|
|
|
|
|
None |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Motorcycle |
|
|
Tractor/SemiTrailer |
|
ATV |
|
|
|
|
|
|
|
|
|||
|
|
Other |
|
|
|
Tractor(2) |
|
|
Farm Equip. |
|
|
|
|
|
Other |
|
||
|
|
RV |
|
|
|
Tractor(3) |
|
|
Unknown Truck |
|
|
|
|
|
|
|
||
ControlTrafficDevice |
|
|
Officer |
|
|
|
Straight/Level |
|
Bridge |
|
|
|
2 Lane |
|
||||
|
|
RR Flashing Signal |
|
|
|
|
|
|
|
|
RoadV29.Design |
|
|
|||||
|
|
|
|
|
|
|
CharacterRoad |
|
Intersect two roads |
|
Private Drive |
|
|
4+ |
|
|||
|
Flag Person |
|
|
RR Signal and Gate |
|
Curve/Level |
|
Crossover |
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
Flashing Signal Red |
|
Signal |
|
|
|
Straight/Grade |
|
Curve/Hillcrest |
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Parking Lot |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V26. |
|
Flashing Signal Yellow |
|
Stop Sign |
|
V28. |
|
|
|
|
|
|
|
|
|
|
||
|
No Passing |
|
|
Railroad Sign |
|
|
|
|
|
|
|
|
1 Lane |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
None |
|
|
|
Yield Sign |
|
|
|
Straight/Hillcrest |
|
Begin/End Divided Road |
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V30. Divided? |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
V27. Device Functioning? |
|
Y |
N |
|
|
Curve/Grade |
|
|
|
V31. Center Turn Lane? |
||||||||
Page
V15. State |
V16. Zip Code |
|
|
|
|
V18. Policy Number
Going Straight
Making Left Turn
Stopped
Slow/Stop in Road
Parked
Backing
Making Right Turn
3 Lane |
|
|
|
Frontage/Ramp |
Type |
||
|
|||
One Way |
|
Surface |
|
|
|
||
Unpaved |
|
Road |
|
|
V32. |
||
Yes |
No |
||
|
|||
Yes |
No |
|
|
of
Avoidance
Lane Change
Leaving Parking
Overtaking/Passing
Parking Position
Making U Turn
In Tow
Type |
None |
|
Right only |
||
Bikeway |
||
Both Sides |
||
|
Left Only |
|
V25. |
Separate |
|
|
Signed |
Asphalt
Concrete
Dirt
Gravel
Other - See Narrative
V33. Towed? |
Yes |
No |
V34. Authority: |
Owner |
Police |
Other |
V35. Towed By: |
Commercial Vehicle
C1. |
Carrier ID Number: |
|
|
US DOT |
|
State |
Mexico |
|||||||
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
C2. Authority |
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
MC |
|
Canada |
|
|
C3. |
Carrier Name |
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4. |
Carrier Address |
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C5. City |
|
|
C6. State |
|
C7. Zip Code |
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C8. GVWR #
9614432302
Type |
Auto transporter |
|
Flatbed |
Bus<15 |
|
Garbage/refuse |
|
Body |
|
||
Bus 15+ |
|
Grain/chips/gravel |
|
|
|
||
Cargo |
Cargo tank |
|
Other |
Concrete Mixer |
|
Pole/log |
|
C9. |
|
||
Dump |
|
Van/enclosed box |
|
|
|
||
|
None |
|
|
C10. Commodity Hauled |
|
|
|
|
C11. Placard ID |
|
|
C12. HAZMAT Released |
Yes |
No |
|
MUCR
Additional Occupants
|
|
O0. Vehicle # |
|
|
O1. |
First Name |
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
O2. Address |
|
|
O3. Address |
|
|
||||
|
Same as |
|
|
|
|
|
|
|||
|
Person # |
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
O4. |
City |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
M |
Race |
|
White |
Hispanic |
||||
|
|
|
|
|
|
|||||
O8. |
|
O9. |
|
|
|
|
|
|||
|
F |
|
Black |
Other |
||||||
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
O0. Vehicle # |
|
|
O1. |
First Name |
|
O15.Xport |
||
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
O2. Address |
|
|
O3. |
Address |
|
|
|||
|
Same as |
|
|
|
|
|
|
|||
|
Person # |
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
O4. |
City |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
M |
Race |
|
White |
Hispanic |
||||
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|||
O8. |
|
F |
O9. |
|
Black |
Other |
||||
|
|
|
|
|||||||
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
O15.Xport |
|
|
O0. Vehicle # |
|
|
O1. |
First Name |
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
O2. Address |
|
|
O3. Address |
|
|
||||
|
Same as |
|
|
|
|
|
|
|||
|
Person # |
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
O4. |
City |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
M |
Race |
|
White |
Hispanic |
||||
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|||
O8. |
|
F |
O9. |
|
Black |
Other |
||||
|
|
|
|
|||||||
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
O0. Vehicle # |
|
|
O1. |
First Name |
|
O15.Xport |
||
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
O3. |
Address |
|
|
|
O2. Address |
|
|
|
|
|||||
|
Same as |
|
|
|
|
|
|
|||
|
Person # |
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
O4. |
City |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
M |
Race |
|
White |
Hispanic |
||||
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|||
O8. |
|
F |
O9. |
|
Black |
Other |
||||
|
|
|
|
|||||||
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Xport |
|
6895084358 |
|
O15. |
|||||||
|
|
|
|
|
|
|
|
|
|
|
Agency NumberAgency Case Number
|
|
|
|
|
|
|
|
Page |
|
o f |
|
|
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||
|
|
|
|
|
|
|
|
|
(2) |
None |
||
|
|
|
|
|
|
PositionO6. |
|
|
Equip.Safety |
|||
|
|
|
|
|
|
Sleeper of Truck Cab |
|
Lap Belt |
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
Automated Restraint |
|||
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
Shoulder Belt |
|||
|
|
O5. State |
|
|
|
|
Riding on Exterior |
|
O7. |
Child Safety Seat |
||
|
|
|
|
Unborn Child |
|
|
||||||
|
|
|
|
|
Towed Vhcl./Trailer |
|
|
Helmet |
||||
AgeO10. |
|
ExtricatedO11. |
|
EjectionO12. |
|
TypeInjuryO13. |
|
|
||||
M |
|
Not |
None |
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||
|
|
|
|
|
|
|||||||
|
|
N |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
Partially |
|
Complaint of Pain |
|
|
Deployed - Side |
No Airbag |
|
|
|
Y |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
Deployed - Both |
|
||
|
|
|
|
|
|
|
|
|
||||
Not Transported |
Police |
|
Hearse |
O16. EMS |
|
|
O17. Medical |
|
|
|||
EMS |
|
Private Vehicle |
|
Agency Code |
|
Facility Code |
|
|
||||
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||
|
|
|
|
|
|
|
|
|
(2) |
None |
||
|
|
|
|
|
|
PositionO6. |
|
|
Equip.Safety |
|||
|
|
|
|
|
|
Sleeper of Truck Cab |
|
Lap Belt |
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
Automated Restraint |
|||
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
Shoulder Belt |
|||
|
|
O5. State |
|
|
|
|
Riding on Exterior |
|
O7. |
Child Safety Seat |
||
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
Unborn Child |
|
Towed Vhcl./Trailer |
|
|
Helmet |
|||
AgeO10. |
|
ExtricatedO11. |
|
EjectionO12. |
|
TypeInjuryO13. |
|
|
||||
M |
|
Not |
None |
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||
|
|
|
|
|
|
|||||||
|
|
N |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
Partially |
|
Complaint of Pain |
|
|
Deployed - Side |
No Airbag |
|
|
|
Y |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
Deployed - Both |
|
||
|
|
|
|
|
|
|
|
|
||||
Not Transported |
Police |
|
Hearse |
O16. EMS |
|
|
O17. Medical |
|
|
|||
EMS |
|
Private Vehicle |
|
Agency Code |
|
Facility Code |
|
|
||||
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||
|
|
|
|
|
|
|
|
|
(2) |
None |
||
|
|
|
|
|
|
PositionO6. |
|
|
Equip.Safety |
|||
|
|
|
|
|
|
Sleeper of Truck Cab |
|
Lap Belt |
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
Automated Restraint |
|||
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
Shoulder Belt |
|||
|
|
O5. State |
|
|
|
|
Riding on Exterior |
|
O7. |
Child Safety Seat |
||
|
|
|
|
Unborn Child |
|
|
||||||
|
|
|
|
|
Towed Vhcl./Trailer |
|
|
Helmet |
||||
AgeO10. |
|
ExtricatedO11. |
|
EjectionO12. |
|
TypeInjuryO13. |
|
|
||||
M |
|
Not |
None |
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||
|
|
|
|
|
|
|||||||
|
|
N |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
Partially |
|
Complaint of Pain |
|
|
Deployed - Side |
No Airbag |
|
|
|
Y |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
Deployed - Both |
|
||
|
|
|
|
|
|
|
|
|
||||
Not Transported |
Police |
|
Hearse |
O16. EMS |
|
|
O17. Medical |
|
|
|||
EMS |
|
Private Vehicle |
|
Agency Code |
|
Facility Code |
|
|
||||
|
|
|
|
Occupant |
|
|
|
|
|
|
|
|
MI |
Last Name |
|
|
|
|
|
|
|
|
Shoulder and Lap Belt |
||
|
|
|
|
|
|
|
|
|
(2) |
None |
||
|
|
|
|
|
|
PositionO6. |
|
|
Equip.Safety |
|||
|
|
|
|
|
|
Sleeper of Truck Cab |
|
Lap Belt |
||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
Encl. Pass./Cargo Area |
|
Automated Restraint |
|||
|
|
|
|
|
|
|
Unencl. Pass./Cargo Area |
|
Shoulder Belt |
|||
|
|
O5. State |
|
|
|
|
Riding on Exterior |
|
O7. |
Child Safety Seat |
||
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
Unborn Child |
|
Towed Vhcl./Trailer |
|
|
Helmet |
|||
AgeO10. |
|
ExtricatedO11. |
|
EjectionO12. |
|
TypeInjuryO13. |
|
|
||||
M |
|
Not |
None |
Life Threatening |
AirbagO14. |
Deployed - Front |
Not Deployed |
|||||
|
|
|
|
|
|
|||||||
|
|
N |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Y |
|
|
|
Partially |
|
Complaint of Pain |
|
|
Deployed - Side |
No Airbag |
|
|
|
Y |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Totally |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Serious |
Killed |
|
Deployed - Both |
|
||
|
|
|
|
|
|
|
|
|
||||
Not Transported |
Police |
|
Hearse |
O16. EMS |
|
|
O17. Medical |
|
|
|||
EMS |
|
Private Vehicle |
|
Agency Code |
|
Facility Code |
|
|
||||