J-1700000-13 SF91 Motor Vehicle Accident Report.pdf

MOTOR VEHICLE

ACCIDENT REPORT

INSTRUCTIONS: Sections I thru IX are filled out by the vehicle operator. Section X, Items 72 thru 82c are filled out by the operator's supervisor. Sections XI thru XIII are filled out by an accident investigator for bodily injury, fatality, and/or damage exceeding $500.

DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (Crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.)

B

23. VEHICLE IS

Please read the Privacy Act State-ment on Page 3.

6. EST. REPAIR COST

SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed.)

SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed.)

A

46.

SECTION I - FEDERAL VEHICLE DATA

4b. WORK TELEPHONE NUMBER

10. SEAT BELTS USED

14b. WORK TELEPHONE NUMBER

15b. HOME TELEPHONE NUMBER

17. ESTIMATED REPAIR COST

22c. TELEPHONE NUMBER

24b. TELEPHONE NUMBER

40. MARK "X" IN TWO APPROPRIATE BOXES 41. IN WHICH VEHICLE

30. MARK "X" IN TWO APPROPRIATE BOXES 31. IN WHICH VEHICLE

b. DIRECTION OF PEDESTRIAN (SW corner to NE corner, etc.)

Pedes-trian

NO

CO-OWNED

LEASED ( )

RENTAL

PRIVATELY OWNED

DRIVER

HELPER

KILLED

INJURED

PASSENGER

PEDESTRIAN

FED

OTHER (2)

FED

OTHER (2)

DRIVER

HELPER

KILLED

INJURED

PASSENGER

PEDESTRIAN

11. DESCRIBE VEHICLE DAMAGE

1. DRIVER'S NAME (Last, first, middle)

4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS

12. DRIVER'S NAME (Last, first, middle)

14a. DRIVER'S WORK ADDRESS

15a. DRIVER'S HOME ADDRESS

16. DESCRIBE VEHICLE DAMAGE

20. MODEL OF VEHICLE

2. DRIVER'S LICENSE NO./STATE/LIMITATIONS

3. DATE OF ACCIDENT

5. TAG OR IDENTIFICATION NUMBER 8. MAKE 9. MODEL

13. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS

21. TAG NUMBER AND STATE 18. YEAR OF VEHICLE 19. MAKE OF VEHICLE

7. YEAR OF VEHICLE

25. OWNER'S ADDRESS(ES)

22b. POLICY NUMBER 22a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS

26. NAME (Last, first, middle)

29. ADDRESS

27. SEX 28. DATE OF BIRTH

34. TRANSPORTED BY

32. LOCATION IN VEHICLE 33. FIRST AID GIVEN BY

24a. OWNER'S NAME(S) (Last, first, middle)

35. TRANSPORTED TO

37. SEX 38. DATE OF BIRTH36. NAME (Last, first, middle)

39. ADDRESS

42. LOCATION IN VEHICLE 43. FIRST AID GIVEN BY

44. TRANSPORTED BY 45. TRANSPORTED TO

a. NAME OF STREET OR HIGHWAY

FROM TO

c.

YES

NSN 7540-00-634-4041

Previous edition not usable

STANDARD FORM 91 PAGE 1 (REV. 2-93)

Prescribed by GSA-FPMR 101-38.6

USAPPC V1.00

91-109 b.

c.

d.

e.

Use one of these outlines to sketch the scene. Write in street or highway names or numbers.

a.

Example:

Use solid line to show path before accident and broken line after the accident

Show pedestrian by

Show railroad by

Place arrow in this circle to indicate NORTH

Number Federal vehicle as 1, other vehicle as 2, additional vehicle as 3 and show direction of travel with arrow.

SECTION VII - POLICE INFORMATION

51.

c. L. FRONT

e. R. REAR

d. REAR

52.

POINT OF IMPACT

(Check one for each vehicle)

49. TIME OF ACCIDENT

SECTION V - WITNESS/PASSENGER (Witness must fill out SF 94, Statement of Witness) (Continue in Section VIII.)

54. WORK TELEPHONE NUMBER

SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)

SECTION IV - ACCIDENT TIME AND LOCATION (Use Section VIII if additional space is needed.)

50. INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED

55. HOME TELEPHONE NUMBER

A

B

59. WORK TELEPHONE NUMBER 60. HOME TELEPHONE NUMBER

63b. OFFICE TELEPHONE NUMBER 63c. HOME TELEPHONE NUMBER

67. ESTIMATED COST

68c. TELEPHONE NUMBER

AREA FED

64b. TELEPHONE NUMBER

PLACE OF ACCIDENT (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection: Kind of locality (industrial, business, residential, open country, etc.); Road description).

g. R. SIDE

a. FRONT

b. R. FRONT

f. L. REAR

h. L. SIDE

1 2

DESCRIBE WHAT HAPPENED (Refer to vehicles "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of the vehicles, road conditions, weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signal, etc.) condition of light (daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making U-turn, passing, stopped in traffic, etc.).

47. DATE OF ACCIDENT 48.

70b. VIOLATION(S)

63d. BUSINESS ADDRESS

64a. NAME OF INSURANCE COMPANY

66. LOCATION OF DAMAGED ITEM

68b. BADGE NUMBER

63a. NAME OF OWNER

56. BUSINESS ADDRESS

58. NAME (Last, first, middle)

61. BUSINESS ADDRESS

53. NAME (Last, first, middle)

57. HOME ADDRESS

62. HOME ADDRESS

63e. HOME ADDRESS

68a. NAME OF POLICE OFFICER

69. PRECINCT OR HEADQUARTERS 70a. PERSON CHARGED WITH ACCIDENT

65. ITEM DAMAGED

64c. POLICY NUMBER

STANDARD FORM 91 PAGE 2 (REV. 2-93)

AM

PM

SECTION VIII - EXTRA DETAILS

In compliance with the Privacy Act of 1974, solicitation of the information requested on this form is authorized by Title 40 U.S.C. Section

491. Disclosure of the information by a Federal employee is mandatory as the first step in the Government's investigation of a motor vehicle accident. The principal purposes for using this information is to provide necessary data for legal counsel in legal actions resulting from the accident and to provide accident information/statistics in analyzing accident causes and developing methods of reducing accidents.

Routine use of information may be by Federal, State or local governments, or agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions. An employee of a Federal agency who fails to report accurately a motor vehicle accident involving a Federal vehicle or who refuses to cooperate in the investigation of an accident may be subject to administrative sanctions.

a.m.

p.m.

a.m.

p.m.

DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHER

THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED.

81.

SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND PAPER.

SECTION IX - FEDERAL DRIVER CERTIFICATION

71b. DRIVER'S SIGNATURE AND DATE

I certify that the information on this form (Sections I thru VIII) is correct to the best of my knowledge and belief.

SECTION X - DETAILS OF TRIP DURING WHICH ACCIDENT OCCURRED

TIME (Circle one)

a. DID THIS ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY

82b. SUPERVISOR'S SIGNATURE AND DATE 82c. TELEPHONE NUMBER

COMPLETED BY

DRIVER'S

SUPERVISOR

75. TRIP BEGAN 76. ACCIDENT

OCCURRED

TIME (Circle one)

IN WRITING (Explain) ORALLY

YES

YES (Explain) NO

YES (Explain) NO NO (Explain)

YES

NO

80.

b. COMMENTS

82a. NAME AND TITLE OF SUPERVISOR

71a. NAME AND TITLE OF DRIVER

72. ORIGIN

74. EXACT PURPOSE OF TRIP

77. AUTHORITY FOR THE TRIP WAS GIVEN TO THE OPERATOR

79. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS

73. DESTINATION

78. WAS THERE ANY DEVIATION FROM DIRECT ROUTE

DATE DATE

STANDARD FORM 91 PAGE 3 (REV. 2-93)

84. PERSONS INTERVIEWED

DATE

88. ACCIDENT REVIEWING OFFICIAL

SECTION XI - ACCIDENT INVESTIGATION DATA

c.

d.

e. OFFICE TELEPHONE NUMBER

e. OFFICE TELEPHONE NUMBER

NAME

SECTION XII - ATTACHMENTS

SECTION XIII - COMMENTS/APPROVALS

a. SIGNATURE AND DATE

87. ACCIDENT INVESTIGATOR

a. SIGNATURE AND DATE

NAME DATE

YES NO (If "Yes", explain below.)

a.

b.

85. ADDITIONAL COMMENTS (Indicate section and item number for each comment.)

83. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION.

LIST ALL ATTACHMENTS TO THIS REPORT

86. REVIEWING OFFICIAL'S COMMENTS

b. NAME (First, middle, last)

c. TITLE

d. OFFICE

b. NAME (First, middle, last)

c. TITLE

d. OFFICE

STANDARD FORM 91 PAGE 4 (REV. 2-93)