Oregon Dmv Forms Details

When you are in an accident, the Oregon DMV requires you to fill out an accident report form. This form is used to collect information about the accident, and can help with investigations and insurance claims. The form is straightforward, but there are a few things to keep in mind when filling it out. In this post, we'll go over the basics of the Oregon DMV accident report form, and what you need to do if you are involved in an accident.

You could find it beneficial to know how much time you'll need to complete this oregon dmv accident report and just how lengthy the form is.

QuestionAnswer
Form NameOregon Dmv Accident Report
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesdmv accident report, oregon accident report form, dmv crash report, oregon department of motor vehicles

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DM V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tear this sheet off your report, read and carefully follow the directions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ONLY drivers involved in an accident resulting in any of the following MUST file an Accident & Insurance Report:

Damage to your vehicle is over $1500

Injury (No matter how minor) Death

Damage to any one person’s property over $1500

Any vehicle has damage over $1500 and any vehicle is towed from the scene as a result of damages

Oregon law requires these reports be filed within 72 hours of the accident. If you are not able to file within the 72 hours, submit it as soon as possible. If you fail to report the accident to DMV, it may result in suspension of your driving privileges. If the police department files a police report, you are still required to file your own Accident and Insurance Report with DMV. If you are an out-of-state resident, you are still required to file your own Accident Report with DMV. DMV does not determine fault in an accident, but does post the accident to the driving record of those drivers required to report, unless the vehicle is parked. If you have questions, please call the Accident Unit at (503) 945-5098.

INSTRUCTIONS

PRINT OR TYPE ALL INFORMATION. (Use black or dark blue ink and press firmly.) Complete both sides of the form.

If additional vehicles were involved in the accident, complete the attached Supplemental Report (Form 735-32B), or on a blank piece of paper, write all the information as requested in Section 4, the “Other Driver” Section.

DMV Headquarters will verify the insurance information submitted. Complete the insurance section or a suspension of your driving privileges may occur.

SECTION 1

DATE, LOCATION AND TIME — Clearly identify the date, location and time of the accident. The correct date, location and time is critical to processing your report. If you are unsure of the county, contact any local law enforcement agency for assistance.

SECTION 2

YOUR VEHICLE (# 1) — DMV will consider your accident uninsured if you do not complete ALL of this section. You must list the insurance company name (not agent) and policy number that provided liability coverage for your operation of the vehicle you were driving at the time of the accident. Note the coverage is for liability insurance, not collision or comprehensive coverage. DMV will verify this information with the insurance company. If the insurance company denies the coverage, DMV will suspend your Oregon driving privileges.

SECTION 3

Answer all of the questions in Section 3. DMV will use the information provided in these questions to code the accident. It is important for you to understand “principal purpose of driving” and “paid to drive.” These include ONLY persons employed or being paid for the purpose of driving, NOT driving to reach a destination to perform a service. Property includes, but is not limited to, fixed or real property, landscaping, signs, parked vehicles, and animals.

COMMERCIAL MOTOR VEHICLE OPERATORS: In addition to this report, Oregon Administrative Rule requires that Form 735-9229, Motor Carrier Crash Report, MUST be filed within 30 days of a commercial motor vehicle accident when there is a FATALITY, INJURY (requiring treatment away from the scene), or when a vehicle is TOWED from the scene because of disabling damage. Form 735-9229 (attached on back) MUST be submitted with Oregon Traffic Accident and Insurance Report (Form 735-32) to DMV. Call (503) 986-3507 for questions regarding the Motor Carrier Crash Report.

SECTION 4

OTHER VEHICLE (# 2) — Completion of this information will help DMV match all driver's accident reports more efficiently. If additional vehicles were involved in the accident, complete attached Supplemental Report (Form 735-32B).

SECTION 5

DESCRIPTION AND SIGNATURE — Describe what happened. It is important for you to sign and date the form.

COMPLETING AND FILING REPORT

OTHER SIDE OF FORM — Complete the other side of the form. Information collected from both sides of this form is used by DMV and other officials in making valuable transportation decisions about the roadway systems and driver safety.

YOUR COPY — Under Oregon law ORS 802.220 (5), DMV can not provide you a copy of your Oregon Traffic Accident and Insurance Report. If you wish to have a complete copy of your report (front and back), you will need to make a copy for your records.

RECEIPT — Attached is a PINK courtesy copy of your report. After you have completed both sides of the form, tear the PINK copy off for your records. If you want a receipt, bring the form, with the PINK copy, to a DMV office and have your copy validated. Without a receipt, you will have no proof of submitting a report.

MAIL — Mail the form to Accident Reporting Unit, DMV, 1905 Lana Ave NE, Salem OR 97314 or FAX to (503) 945- 5267, or deliver it to any DMV office.

PURSUANT TO OREGON INSURANCE LAW, AN INSURANCE COMPANY CAN NOT REQUIRE REPAIRS BE MADE TO A MOTOR VEHICLE BY A PARTICULAR PERSON OR REPAIR SHOP.

735-32 (7-17)

 

STK# 300009

TOTALED VEHICLE NOTICE

DEFINITIONS AND INSTRUCTIONS FOR TOTALED VEHICLES

IF YOUR ACCIDENT HAS RESULTED IN A “TOTALED” VEHICLE, YOU ARE REQUIRED BY LAW TO

FOLLOW APPROPRIATE INSTRUCTIONS IN THIS NOTICE.

DEFINITION OF “TOTALED” VEHICLE

“Totaled Vehicle” or “Totaled” as defined in Oregon law (ORS 801.527) means:

A vehicle that is declared a total loss by an insurer who is obligated to cover the loss or a vehicle that the insurer takes possession of or title to.

A vehicle that has sustained damage that is not covered by an insurer and the estimated cost to repair the vehicle is equal to at least 80% of the retail market value prior to the damage. “Retail market value” is defined as the amount shown in publications used by financial institutions (banks or lenders) in this state.

A vehicle that is stolen, if it is not recovered within 30 days of theft and the loss is not covered by an insurer. In this situation, you must notify DMV within 60 days of the theft.

FOLLOW THESE INSTRUCTIONS IF YOUR VEHICLE IS TOTALED

 

 

If your vehicle is totaled, in addition to completing the accident report, follow the instruction that is applicable to your case. Either:

1.SURRENDER the title to the insurer if the damage is covered by an insurer who declares the vehicle to be a “total loss,” and the insurer takes possession of the vehicle; or

2.SURRENDER the title to DMV and apply for salvage title if the damage is covered by an insurer who declares the vehicle to be a “total loss,” but you keep possession of the vehicle; or

3.SURRENDER the title to DMV and apply for salvage title if the damage was not covered by an insurer and the estimated cost of repair is at least 80% of the retail market value of the vehicle before the damage; or

4.NOTIFY DMV that your vehicle has been totaled if, for some reason, you are unable to obtain the title for surrender. You must provide DMV with a signed statement which includes:

A description of the vehicle which includes the year model, make, plate number and vehicle identification number.

A statement indicating the vehicle has been totaled.

A statement that you are unable to obtain the title and why.

DO NOT SUBMIT THE TITLE WITH THE ACCIDENT REPORT. You can obtain the Application for Salvage Title (Form 735-229) from any DMV office, by calling (503) 945-5000, or on-line at www.oregondmv.com. Application instructions and fee information are on the back of the form 735-229. If you have questions about salvage titles, call (503) 945-5122.

NOTE: It is a Class A misdemeanor with a penalty of imprisonment and/or fine if you fail to comply with the above requirements. (ORS 819.012)

 

 

 

DM V

 

 

OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE BOTH SIDES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete this form ONLY if your accident happened on a highway or premises open to the public, and resulted in any of the following: 1) More than $1500 in damage to your vehicle; 2) More than $1500 in damage to any one person's property other than a vehicle; 3) Any vehicle has more than $1500 and any vehicle is towed from the scene as a result of damages; 4) Injury to any person (no matter how minor the injury); or, 5) the death of any person.

SECTION 1

ACCIDENT DATE

DAY OF WEEK

 

TIME OF DAY

COUNTY

 

DO NOT WRITE IN

Accident

 

 

 

 

 

 

 

 

 

M T W TH F

 

 

 

AM

 

 

 

THIS SPACE

Number

 

 

 

 

 

 

 

 

 

 

S SN

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )

MILE POST

TYPE OF ACCIDENT - The accident involved one or more of the following: (Mark all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two vehicles

 

 

ATV / Snowmobile

 

 

Parked vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

More than two vehicles

 

 

Motorcycle

 

 

Overturned vehicle

 

 

 

WITHIN

FEET

N

S

E

W

NAME OF NEAREST INTERSECTING ROAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEAR

 

MILES

N

S

E

W

 

 

 

 

 

Fatality

 

 

Motorized Scooter

 

 

Animal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bicycle

 

 

Personal (assisted)

 

 

Fixed object / property

 

 

 

WITHIN

FEET

N

S

E

W

NAME OF NEAREST CITY / TOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mobility device

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEAR

 

MILES

N

S

E

W

 

 

 

 

 

Pedestrian

 

 

Train

 

 

Other ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 (YOUR VEHICLE # 1)

Complete ALL of this section. If you fail to do so, your driving privileges may be suspended. You MUST list the insurance company (not agen ) and policy number that provided liability coverage for the vehicle you were driving.

 

DRIVER’S NAME (LAST, FIRST, MIDDLE)

 

DRIVER’S LICENSE NUMBER

STATE

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

M F X

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S RESIDENCE ADDRESS

 

CITY

STATE

ZIP CODE

 

 

CHECK BOX

 

 

 

 

 

 

 

 

 

 

 

 

IF ADDRESS

 

 

 

 

 

 

 

 

 

CHANGE

 

MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE)

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

 

CITY

STATE

ZIP CODE

 

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY NAME (NOT AGENCY) AND ADDRESS

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR MAKE & MODEL

Check all statements that apply:

SECTION 3

Damage to your vehicle was more than $1500.

Damage to any one person’s property (other than vehicle) was more than $1500.

Your vehicle was towed from the scene as a result of damages.

You or passengers in your vehicle were injured.

The accident occured while you were driving your employer’s vehicle.

You were driving on your job and being paid for the principal purpose of driving. You were being paid to drive and/or deliver persons or property.

You were operating a government owned vehicle marked for transporting mail in accordance with government rules. You were operating an authorized emergency vehicle.

You were operating a commercial motor vehicle requiring you to have a commercial driver license.

You were transporting hazardous material.

The accident occurred in a work or maintenance zone.

A police officer came to the scene.

Name of police department: __________________________________ City County State Police

A citation was issued to you. The citation was: ________________________________________________________

SECTION 5SECTION 4 (OTHER VEHICLE # 2)

 

DRIVER’S NAME (LAST, FIRST, MIDDLE)

 

DRIVER’S LICENSE NUMBER

STATE

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

M F X

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

 

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

 

CITY

STATE

ZIP CODE

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY NAME (NOT AGENT) AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR MAKE & MODEL

IF ADDITIONAL VEHICLES WERE INVOLVED IN THE ACCIDENT, USE ATTACHED SUPPLEMENTAL REPORT (Form 735-32B).

DESCRIBE WHAT HAPPENED: (IF MORE SPACE IS NEEDED, SUBMIT ADDITIONAL PAGE)

I certify all information given on this report is true and accurate to the best of my knowledge.

SIGNATURE OF PERSON MAKING REPORT

PRINTED NAME OF PERSON MAKING REPORT

DAYTIME PHONE #

DATE SIGNED

X

 

(

)

 

IF NOT DRIVER’S SIGNATURE, STATE RELATIONSHIP

REASON DRIVER IS UNABLE TO SIGN REPORT

 

PHONE NUMBER OF DRIVER

 

 

 

(

)

 

 

 

 

735-32 (7-17)

COMPLETE THE OTHER SIDE OF THIS PAGE

STK# 300009

YOU INTENDED TO...

Go straight ahead

Make right turn

Make left turn

Make “U” turn

Back–Up

Enter driveway (also mark left or right turn)

Remain stopped in traffic Enter parked position

Slow or Stop

Leave driveway (also mark left or right turn)

Start in traffic lane

Leave parked position Remain parked

Overtake and pass

YOUR VEHICLE

Passenger car, pickup, van Military vehicle

Taxicab

Emergency vehicle

Any of the above and trailer

Private or public agency transit vehicle

Bus School bus

Other publicly-owned veh.

Motorcycle

Motor–scooter/bike

Personal (assisted) mobility device

Truck tractor & semi trailer Truck/truck tractor

Other truck combination

Farm tractor/farm equip.

WEATHER CONDITIONS

Clear

Raining

Snowing

Fog

Other

ROAD SURFACE

Dry

Wet

Snowy

Icy

Other

LIGHT CONDITIONS

Daylight

Dawn or dusk

Darkness (lighted)

Darkness (unlighted) Other

YOUR RESIDENCE Local resident

(within 25 miles of accident site)

Residing elsewhere in state

Non–resident of this state:

College student

Military Temporary job

YOU WERE HEADED

North East

South West

On: ____________________

(name of street, road or route)

OTHER DRIVER WAS HEADED

North East

South West

On: ____________________

(name of street, road or route)

WITNESS INFORMATION:

DRIVER AND PASSENGER INJURY AND SAFETY EQUIPMENT INFORMATION

If this accident involved a pedestrian or

bicyclist, complete the following:

PEDESTRIAN NAME

BICYCLIST NAME

Pedestrian or bicyclist was going:

 

N

S

E

W

SAFETY EQUIPMENT CODES

WRITE one of the codes (0–10) in column C

0 No seat belt available

1Seat belt available but NOT used

2 Seat belt available and in use

3 Child restraint device available

4 Child restraint device in use

5 Child restraint device not available

6 Helmet NOT in use

7 Helmet in use

8 Air bag deployed

9 Air bag available - NOT deployed

10 Air bag NOT available

INJURY CODE FOR OCCUPANTS

WRITE one of the codes (1–5) in column D

1.Deceased as a result of the accident

2.Incapacitated - unconscious, could not walk, broken or distorted limbs, etc.

3.Visible injury - lump, abrasion cuts

4.Momentary unconsciousness, complaint of pain, nausea, limping

5.No apparent injury

SEX CODE

WRITE M, F or X in column A

ALONG OR ACROSS: (name of street, road or route)

From:

To:

EXAMPLE: (From: NE corner To: SE corner (or) From: East side To: West side, etc.)

Sex and age of pedestrian / bicyclist:

 

M

F

X

Age: _____

Extent of pedestrian / bicyclist injury:

 

Deceased

 

Momentary unconscious-

 

 

SEAT

PASSENGER’S NAMES (your vehicle)

A

B

C

 

D

POSITION

SEX

AGE

SFTY

 

AIR

INJURY

 

EQP

 

BAG

DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRONT

CENTER

FRONT

RIGHT

MIDDLE*

LEFT

MIDDLE *

CENTER

MIDDLE *

RIGHT

REAR

LEFT

REAR

CENTER

REAR

RIGHT

*Use only for vehicles with middle row of seats (i.e., vans, SUVs, etc.)

Incapacitated

ness / complaint of pain

Visible injury

No apparent injury

Pedestrian / bicyclist action: (mark one)

Crossing at intersection or crosswalk Crossing not at intersection or crosswalk Walking / riding in roadway with traffic Walking / riding in roadway against traffic Standing in roadway

Pushing or working on vehicles in roadway Other working in road

Playing in road Hitchhiking Not in roadway

Other________________________________

(specify)

Vehicle Damage

FRONT

 

USE ARROW TO SHOW

Vehicle towed

FIRST IMPACT (SHADE

Rollover

IN DAMAGED AREA)

Under car

Totaled

Unknown

Your Vehicle (No. 1) damage: $ __________ .

Diagram

Number each vehicle:

 

Show path by:

Show pedestrian/bicyclist by:

Show railroad tracks by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(name of street,

 

 

(name of street,

 

road or route)

 

 

 

 

road or route)

(name of street, road or route)

SUPPLEMENTAL REPORT

OREGON TRAFFIC ACCIDENT

Supplemental for more than two drivers involved in the crash.

Attach this form to your OREGON TRAFFIC ACCIDENT AND INSURANCE REPORT.

ACCIDENT DATE

DAY OF WEEK

TIME OF DAY

 

COUNTY

 

 

 

 

M T W TH F

 

AM

 

 

 

S SN

 

PM

 

 

 

 

 

 

 

ROAD ON WHICH ACCIDENT OCCURRED (Name of street, road or route )

MILE POST

 

 

 

 

 

 

 

 

 

 

 

 

DO NOT WRITE

IN THIS SPACE

 

VEHICLE

INSURANCE COMPANY NAME (NOT AGENCY)

 

POLICY NUMBER

 

 

 

 

 

#3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

 

STATE

 

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

 

 

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

INSURANCE COMPANY NAME (NOT AGENCY)

 

POLICY NUMBER

 

 

 

 

 

#4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

 

STATE

 

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

 

 

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

INSURANCE COMPANY NAME (NOT AGENCY)

 

POLICY NUMBER

 

 

 

 

 

#5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

 

STATE

 

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

 

 

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

INSURANCE COMPANY NAME (NOT AGENCY)

 

POLICY NUMBER

 

 

 

 

 

#6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

 

STATE

 

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

 

 

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

INSURANCE COMPANY NAME (NOT AGENCY)

 

POLICY NUMBER

 

 

 

 

 

#7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER

VEHICLE PLATE NUMBER

STATE

YEAR

MAKE & MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER’S FULL NAME (LAST, FIRST, MIDDLE)

DRIVER’S LICENSE NUMBER

 

STATE

 

DATE OF BIRTH

SEX (CIRCLE)

 

 

 

 

 

 

 

 

 

 

M

F

X

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER’S ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE OWNER’S NAME AND ADDRESS

CITY

 

 

STATE

ZIP CODE

 

 

 

 

SAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

735-32B (7-17)

 

 

 

 

 

 

 

STK# 300026

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLEMENTAL REPORT – USE IF MORE THAN TWO VEHICLES

OREGON DEPARTMENT OF

MOTOR CARRIER CRASH REPORT

TRANSPORTATION ACCIDENT REPORTING

 

UNIT DRIVER AND MOTOR VEHICLE SERVICES

 

1905 LANA AVE. NE

 

SALEM OR 97314

 

FAX: (503) 945-5267

 

INSTRUCTIONS: IF YOU CHECKED A BOX UNDER THE QUALIFYING VEHICLE COLUMN AND A BOX UNDER THE CRITERIA COLUMN, COMPLETE THE REMAINDER OF THE MOTOR CARRIER CRASH REPORT AND SUBMIT TO THE ADDRESS SHOWN ABOVE. IF NO CIRCUMSTANCES LISTED UNDER THE CRITERIA COLUMN APPLY, YOU ARE NOT REQUIRED TO SUBMIT THE MOTOR CARRIER CRASH REPORT. IF YOU HAVE ANY QUESTIONS REGARDING FILLING OUT THE MOTOR CARRIER CRASH

REPORT, PLEASE CALL (503) 986-3507.

 

QUALIFYING VEHICLE

 

 

 

 

 

 

 

 

 

CRITERIA

 

 

 

 

 

 

 

 

 

COMMERCIAL TRUCK (GVWR OVER 10,000 LBS OR ACTUAL WT

 

ANY PERSON SUSTAINING A FATALITY (WITHIN 30 DAYS OF THE

 

AT TIME OF CRASH EVEN IF GVWR IS SET UNDER 10,000 LBS )

 

 

 

ACCIDENT)

 

 

 

 

 

 

 

 

 

HAZARDOUS MATERIAL PLACARD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANY PERSON SUSTAINING INJURIES REQUIRING TREATMENT AWAY

 

COMMERCIAL BUS (DESIGNED FOR 8 OR MORE PASSENGERS)

 

 

 

FROM THE SCENE

 

 

 

 

 

 

 

FARM TRUCK INTERSTATE (OVER 10,000 LBS.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANY VEHICLE INCURRING DISABLING DAMAGE REQUIRING

 

FARM TRUCK FOR-HIRE (4 OR MORE AXLES)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMOVAL FROM THE SCENE BY A TOW TRUCK OR ANOTHER

 

FARM TRUCK TOWING TRIPLE TRAILERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR VEHICLE

 

 

 

 

 

 

 

FARM TRUCK (OVER 80,000 LBS.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR CARRIER NAME

 

 

 

 

 

 

 

 

US DOT NUMBER

 

 

 

 

AUTHORITY/FILE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

LENGTH OF EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEARS

 

MONTHS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CDL / DL NUMBER

 

 

STATE

 

 

 

 

 

LICENSE CLASS

 

 

 

 

EXPIRATION DATE OF MEDICAL CERTIFICATE

 

 

 

 

 

 

 

 

 

 

 

 

A

B

C

 

D

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE ACCIDENT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AT TIME OF THE ACCIDENT, TOTAL HOURS

 

 

 

 

TOTAL HOURS ON DUTY DURING THE PREVIOUS

 

 

7 CONSECUTIVE DAYS ____________

 

DRIVING SINCE LAST OFF-DUTY PERIOD.

 

 

 

 

(FILL OUT ONE ONLY, BASED ON TIME DOCUMENTS)

 

 

8 CONSECUTIVE DAYS ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES YOUR DRIVER HAVE A MEDICAL WAIVER

 

 

 

TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER INJURY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR DRIVER KILLED

 

YOUR DRIVER INJURED

 

 

RELIEF DRIVER KILLED

RELIEF DRIVER INJURED

 

TOTAL NUMBER OF PASSENGERS

 

YES

NO

 

YES

NO

 

YES

NO

 

YES

NO

 

_____KILLED _____ INJURED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER DRIVER INJURY INFORMATION

TOTAL NUMBER OF OTHER DRIVERS

_____KILLED

_____ INJURED

TOTAL NUMBER OF OTHER PASSENGERS

 

TOTAL NUMBER OF PEDESTRIANS

 

TOTAL NUMBER OF BICYCLISTS

_____KILLED

_____ INJURED

 

_____KILLED

_____ INJURED

 

_____KILLED

_____ INJURED

 

 

 

 

 

 

 

 

OTHER MOTOR CARRIER INFORMATION (IF 2 OR MORE MOTOR CARRIERS WERE INVOLVED)

MOTOR CARRIER NAME

VEHICLE LICENSE # AND STATE

DRIVER'S NAME

DRIVER'S LICENSE # AND STATE

MOTOR CARRIER VEHICLE INFORMATION

YEAR MAKE

UNIT NUMBER

TRUCK/TRACTOR/BUS LICENSE PLATE NO. & STATE TOTAL NO. OF AXLES INCLUDING TRAILERS

VEHICLE TYPE (SELECT APPROPRIATE

TYPE)

1

Triples (tractor with 3 trailers

2

Triples (truck with 2 trailers)

5

Standard

 

Tractor/Semi Trailer

6

Straight Truck

9

Heavy Haul

 

10

Bus/Van (8 or more

passenger capacity)

 

3

4

Straight truck-full trailer

Doubles (any)

7

Bobtail

 

8

Saddlemount

 

11

Auto/Pickup

735-9229 (4-15)

COMPLETE REVERSE SIDE

SUPPLEMENTAL – MOTOR CARRIER CRASH REPORT

CARGO BODY TYPE (CIRCLE ONE)

 

 

 

 

 

 

 

 

VAN FLATBED TANKER

CONTAINER

POLE

DUMP BELLY-DUMP CAR CARRIER

 

LIVESTOCK

MOBILE HOME TOTER PASSENGER DROP-BOX

GARBAGE

BULK-HOPPER MIXER

SADDLEMOUNT

WRECKER FIXED LOAD

HEAVY HAUL

UTILITY

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL LENGTH OF VEHICLE/COMB

 

TOTAL WIDTH OF VEHICLE OR CARGO

 

CARGO WEIGHT

 

GROSS VEHICLE WEIGHT

 

 

 

 

 

 

 

 

 

COMMODITY INFORMATION

COMMODITY BEING TRANSPORTED AT TIME OF CRASH

WAS A HAZARDOUS COMMODITY BEING HAULED

WAS HAZARDOUS MATERIAL RELEASED FROM

 

 

HAZARD CLASS

 

 

 

 

 

YES

NO

THE VEHICLE CARGO(NOT A FUEL RELEASE)

YES

NO

 

 

 

 

 

 

 

CRASH INFORMATION

LOCATION OF CRASH (NEAREST CITY OR TOWN)

HIGHWAY AND MILEPOINT/STREET/COUNTY ROAD

DIRECTION OF YOUR VEHICLE (CIRCLE)

N S E W

DATE OF CRASH

TIME

AM PM

DAY OF THE WEEK (CIRCLE ONE)

MON TUES WED THU FRI SAT SUN

CONDITIONS AT TIME OF ACCIDENT

WEATHER (CIRCLE ONE)

1. CLEAR

2. RAIN

3. SNOW

4. CLOUDY

5. SLEET

6. FOG

7. OTHER

ROAD SURFACE (CIRCLE ONE)

1. DRY

2. WET

3. SNOWY

4. ICY

5. OTHER

 

 

 

LIGHT CONDITION (CIRCLE ONE)

1. DAY

2. DAWN

3. DUSK

4. ARTIFICIAL LIGHTS

5. DARK

6. OTHER

 

DESCRIBE WHAT HAPPENED BY CHECKING ALL BOXES THAT APPLY. YOUR VEHICLE IS ALWAYS NO.1. IF OTHER VEHICLES WERE INVOLVED, COMPLETE COLUMNS 2 & 3 TO CORRESPOND TO THE ACTIONS OF THE SAME NUMBERED VEHICLES LISTED ABOVE UNDER "OTHER DRIVER INFORMATION".

VEHICLES

1 2 3

ACTION

SLOWING - STOPPING

STOPPED

REAR-END

BACKING

MAKING RIGHT TURN

MAKING LEFT TURN

MAKING U TURN

PROCEEDING STRAIGHT

INTERSECTION

ENTERING TRAFFIC (FROM SHOULDER, MEDIAN, PARKING STRIP OR PRIVATE DRIVE)

VEHICLES

1 2 3

ACTION

PASSING

CHANGING LANES

SIDESWIPE

HEAD-ON

SKIDDING

VEHICLE OUT OF CONTROL

ROLL-AWAY

CONTROLLED RR CROSSING

UNCONTROLLED RR CROSSING

RAN OFF ROAD

VEHICLES

1 2 3

ACTION

JACKKNIFE

OVERTURN

SEPARATION OF UNITS

FIRE

EXPLOSION

CARGO SHIFT

CARGO SPILL (HAZARDOUS)

CARGO SPILL (NON-HAZARDOUS)

OTHER (DEER, GUARDRAIL, ETC)

DID YOUR VEHICLE STRIKE A PARKED VEHICLE

YES NO

WAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE

YES NO

DESCRIPTION OF ACCIDENT BY CARRIER OFFICIAL

NAME AND TITLE OF PERSON SIGNING REPORT

TELEPHONE NUMBER(S)

SIGNATURE I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE

DATE

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