Attachment 19-SF-91 - Motor Vehicle Accident Report Form.pdf
Standard Form PDF 227 KB Posted
- Attached to
- Student Support RFP Artesia, NM FLETC
- Solicitation number
- 70LART25RPFB00005
About this file
This is Standard Form 91 (SF-91), the federal Motor Vehicle Accident Report form used to document motor vehicle accidents involving federal vehicles and employees. The four-page form contains sections for federal vehicle data, other vehicle data, information about killed or injured persons, accident time and location details, witness/passenger information, property damage, police information, driver certification, trip details, and accident investigation data.
The form is specifically designed to collect comprehensive accident information, including vehicle identification, damage descriptions, insurance details, and a diagram to illustrate how the accident occurred. It requires input from multiple parties - the vehicle operator completes Sections I through IX, the operator's supervisor completes Section X, and an accident investigator completes Sections XI through XIII for accidents involving bodily injury, fatality, and/or damage exceeding $500. This form appears to be an attachment to a Federal Law Enforcement Training Center (FLETC) solicitation related to student support services and driver training in Artesia, NM.
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Text version
1_DRIVERS_NAME_Last_first:
| 2_DRIVERS_LICENSE_NOSTATE: |
| 3_DATE_OF_ACCIDENT: |
| 4a_DEPARTMENTFEDERAL_AGEN: |
| Comb1: |
| Comb11: |
| 5_TAG_OR_IDENTIFICATION_N: |
| FillText6: |
| 7_YEAR_OF_VEHICLE: |
| 8_MAKE: |
| 9_MODEL: |
| 10_SEAT_BELTS_USED: Off |
| 1_1_DESCRIBE_VEHICLE_DAMA: |
| 12_DRIVERS_NAME_Last_firs: |
| 13_DRIVERS_LICENSE_NUMBER: |
| 14a_DRIVERS_WORK_ADDRESS: |
| Comb2: |
| Comb21: |
| 15a_DRIVERS_HOME_ADDRESS: |
| Comb3: |
| Comb31: |
| 16_DESCRIBE_VEHICLE_DAMAG: |
| FillText7: |
| 18_YEAR_OF_VEHICLE: |
| 19_MAKE_OF_VEHICLE: |
| 20_MODEL_OF_VEHICLE: |
| 21_TAG_NUMBER_AND_STATE: |
| 22a_DRIVERS_INSURANCE_COM: |
| 22b_POLICY_NUMBER: |
| Comb4: |
| Comb41: |
| COOWNED: Off |
| LEASED: Off |
| RENTAL: Off |
| PRIVATELY_OWNED: Off |
| 24a_OWNERS_NAMES_Last_fir: |
| Comb5: |
| Comb51: |
| SECTION_III__KILLED_OR_IN: |
| 26_NAME_Last_first_middle: |
| 27_SEX: |
| 28_DATE_OF_BIRTH: |
| 29_ADDRESS: |
| KILLED1: Off |
| INJURED1: Off |
| DRIVER1: Off |
| HELPER1: Off |
| PASSENGER1: Off |
| PEDESTRIAN1: Off |
| FED1: Off |
| OTHER_2: Off |
| 32_LOCATION_IN_VEHICLE: |
| 33_FIRST_AID_GIVEN_BY: |
| 34_TRANSPORTED_BY: |
| 35_TRANSPORTED_TO: |
| 36_NAME_Last_first_middle: |
| 37_SEX: |
| 38_DATE_OF_BIRTH: |
| 39_ADDRESS: |
| KILLED2: Off |
| INJURED2: Off |
| DRIVER2: Off |
| HELPER2: Off |
| PASSENGER2: Off |
| PEDESTRIAN2: Off |
| FED2: Off |
| OTHER_1: Off |
| 42_LOCATION_IN_VEHICLE: |
| 43_FIRST_AID_GIVEN_BY: |
| 44_TRANSPORTED_BY: |
| 45_TRANSPORTED_TO: |
| a_NAME_OF_STREET_OR_HIGHW: |
| FROM: |
| TO: |
| c_DESCRIBE_WHAT_PEDESTRIA: |
| 47_DATE_OF_ACCIDENT: |
| 48_PLACE_OF_ACCIDENT_Stre: |
| FillText8: |
| FillText9: |
| FED3: |
| FED4: |
| FED5: |
| FED6: |
| FED7: |
| FED8: |
| FED9: |
| FED10: |
| 1: |
| 3: |
| 4: |
| 5: |
| 6: |
| 7: |
| 8: |
| 9: |
| SECTION_V__WITNESSPASSENG: |
| 53_NAME_Last_first_middle: |
| Comb7: |
| Comb71: |
| Comb8: |
| Comb81: |
| 56_BUSINESS_ADDRESS: |
| 57_HOME_ADDRESS: |
| 58_NAME_Last_first_middle: |
| Comb9: |
| Comb91: |
| Comb10: |
| Comb101: |
| 61_BUSINESS_ADDRESS: |
| 62_HOME_ADDRESS: |
| 63a_NAME_OF_OWNER: |
| Comb111: |
| Comb6: |
| Comb12: |
| Comb121: |
| 63d_BUSINESS_ADDRESS: |
| 63e_HOME_ADDRESS: |
| 64a_NAME_OF_INSURANCE_COM: |
| Comb13: |
| Comb131: |
| 64c_POLICY_NUMBER: |
| 65_ITEM_DAMAGED: |
| 66_LOCATION_OF_DAMAGED_IT: |
| 67_ESTIMATED_COST: |
| 68a_NAME_OF_POLICE_OFFICE: |
| 68b_BADGE_NUMBER: |
| Comb14: |
| Comb141: |
| 69_PRECINCT_OR_HEADQUARTE: |
| 70a_PERSON_CHARGED_WITH_A: |
| 70b_VIOLATIONS: |
| SECTION_IX__FEDERAL_DRIVE: |
| 71_a_NAME_AND_TITLE_OF_DR: |
| 72_ORIGIN: |
| 73_DESTINATION: |
| FillText10: |
| DATE1: |
| FillText11: |
| FillText12: |
| DATE2: |
| FillText13: |
| FillText14: |
| ORALLY: Off |
| IN_WRITING_Explain: Off |
| FillText15: |
| 78_WAS_THERE_ANY_DEVIATIO: Off |
| FillText16: |
| 79_WAS_THE_TRIP_MADE_WITH: Off |
| FillText17: |
| 80_DID_THE_OPERATOR_WHILE: Off |
| FillText18: |
| a_DID_THIS_ACCIDENT_OCCU1: Off |
| b_COMMENTS: |
| 82a_NAME_AND_TITLE_OF_SUP: |
| 71b_DRIVER_DATE: |
| Comb15: |
| Comb151: |
| SECTION_XI__ACCIDENT_INVE: Off |
| 84_PERSONS_INTERVIEWED: |
| a_b: |
| DATE3: |
| FillText20: |
| FillText21: |
| d_C: |
| DATE4: |
| FillText19: |
| FillText22: |
| SECTION_XII__ATTACHMENTS: |
| SECTION_XIII__COMMENTSAPP: |
| FillText23: |
| 82b_SUPERVISOR_DATE: |
| b_NAME_First_middle_last: |
| c_TITLE: |
| d_OFFICE: |
| Comb16: |
| Comb161: |
| 87a_date: |
| 88a_date: |
| b_NAME_First_middle_last1: |
| c_TITLE1: |
| d_OFFICE1: |
| Comb17: |
| Comb171: |
File details come from the government source that posted it. Updated .