REPORT OF MOTOR VEHICLE ACCIDENT (AR-13)



REPORT OF MOTOR VEHICLE ACCIDENT--- STATE OF WEST VIRGINIAINSTRUCTIONS: After completing the online form, forward copy to District Equipment Supervisor for review and distribution.AR-13 -- REV. 02-07-2019DO NOT COMPLETE FORMTEXT ?????Risk Code: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ReferenceDEPT/AGENCY NAME FORMTEXT ?????Date:DATE OF ACCIDENT:MONTHDAYYEARDAY OF WEEK:(Check One)M FORMCHECKBOX 1T FORMCHECKBOX 2W FORMCHECKBOX 3Th FORMCHECKBOX 4F FORMCHECKBOX 5S FORMCHECKBOX 6Sun FORMCHECKBOX 7TIME OFACCIDENT: FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PM FORMTEXT ?????NUMBER OF VEHICLESINVOLVED IN ACCIDENT: FORMTEXT ??NUMBERINJURED: FORMTEXT ??NUMBERKILLED: FORMTEXT ??ACCIDENT WASINVESTIGATED BY:1 FORMCHECKBOX 2 FORMCHECKBOX State PoliceCity Police3 FORMCHECKBOX 4 FORMCHECKBOX SheriffNone of AboveLOCATIONCOUNTY FORMTEXT ?????CITY OR TOWNHIGHWAY CLASSIFICATION FORMCHECKBOX FORMCHECKBOX INNEAR FORMTEXT ?????1 FORMCHECKBOX 2 FORMCHECKBOX InterstateU. S.3 FORMCHECKBOX 4 FORMCHECKBOX W. Va.County5 FORMCHECKBOX 6 FORMCHECKBOX CityOtnerACCIDENTOCCURREDON:ROUTE 1 FORMTEXT ?????OrSTREET 1 FORMTEXT ?????CODE FORMTEXT ?????IF ON CONTROLLED ACCESS HIGHWAY, CHECK ONE1 FORMCHECKBOX 2 FORMCHECKBOX Main RoadMain Road at InterchangeATINTERSECTIONWITH:ROUTE 2 FORMTEXT ?????OrSTREET 2 FORMTEXT ?????CODE FORMTEXT ?????3 FORMCHECKBOX 4 FORMCHECKBOX Entrance Ramp OnExit Ramp OnN FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX N FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX IF NOT ATINTERSECTION: FORMTEXT ???? FORMCHECKBOX FEET FORMCHECKBOX MILESOFSTREET, HIGHWAY, TOWN, ETC. FORMTEXT ?????CODE FORMTEXT ?????N FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX SPECIALREFERENCE:IF LOCATION CAN BE DESCRIBED MORE PRECISELY, ENTER HERE FORMTEXT ?????MILEPOST FORMTEXT ?????TOLERANCE FORMTEXT ?????STATEDRIVERYOUR FULL NAME (Please Print) FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????DATE OF BIRTH:MONTH FORMTEXT ?????DAY FORMTEXT ??YEAR FORMTEXT ?? FORMCHECKBOX Male FORMCHECKBOX FemaleDRIVER'S LICENSE NUMBER FORMTEXT ?????STATE FORMTEXT ?????Have you taken the National Safey Council's Defensive Driving Course? FORMTEXT ???If Yes, Certificate No. FORMTEXT ?????DRIVERACTION:(Check One)1 FORMCHECKBOX Going Straight Anead2 FORMCHECKBOX Turning Right3 FORMCHECKBOX Turning Left4 FORMCHECKBOX U - Turning5 FORMCHECKBOX Changing Lanes6 FORMCHECKBOX Passing7 FORMCHECKBOX Parking8 FORMCHECKBOX Parked9 FORMCHECKBOX Backing10 FORMCHECKBOX Merging11 FORMCHECKBOX Slowing or Stopping12 FORMCHECKBOX Stopped in Traffic Lane13 FORMCHECKBOX Entering or Leaving Driveway14 FORMCHECKBOX Pulling Out from Parking Space15 FORMCHECKBOX OtherVEHICLE #1STATEVEHICLEASSIGNED TO: ORGANIZATION, DISTRICT, COUNTY FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????POINT OF IMPACTYEAR FORMTEXT ??MAKE FORMTEXT ?????MODEL FORMTEXT ?????BODY STYLE FORMTEXT ?????LICENSE PLATE NUMBER FORMTEXT ?????STATE FORMTEXT ?????7 DIGIT VEHICLE ED NO. FORMTEXT ???? - FORMTEXT ????VIN NO. FORMTEXT ?????TOTAL OCCUPANTSOF THIS VEHICLE: FORMTEXT ??DIRECTION OF TRAVEL: (If turning, enter direction BEFORE turn.)ONROUTE(Or Street) FORMCHECKBOX 1 FORMCHECKBOX 2 (See LOCATION Section Above)N FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX APPROXIMATE COST TO REPAIR $ FORMTEXT ????? FORMCHECKBOX Total LossAREA(S) Select Number(s) from Diagram →INITIALDAMAGED: FORMTEXT ?????IMPACT: FORMTEXT ?Name of State Employee responsible for repairs of State Vehicle: FORMTEXT ?????Location: FORMTEXT ?????Telephone: FORMTEXT ?????OTHERDRIVEROTHER DRIVER'S FULL NAME FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX FemaleDRIVER'S LICENSE NUMBER FORMTEXT ?????STATE FORMTEXT ?????DRIVERACTION:(Check One)1 FORMCHECKBOX Going Straight Ahead2 FORMCHECKBOX Turning Right3 FORMCHECKBOX Turning Left4 FORMCHECKBOX U - Turning5 FORMCHECKBOX Changing Lanes6 FORMCHECKBOX Passing7 FORMCHECKBOX Parking8 FORMCHECKBOX Parked9 FORMCHECKBOX Backing10 FORMCHECKBOX Merging11 FORMCHECKBOX Slowing or Stopping12 FORMCHECKBOX Stopped in Traffic Lane13 FORMCHECKBOX Entering or Leaving Driveway14 FORMCHECKBOX Pulling Out from Parking Space15 FORMCHECKBOX OtherOTHERVEHICLEOWNER'S FULL NAME FORMCHECKBOX Same as Driver FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????POINT OF IMPACTYEAR FORMTEXT ??MAKE FORMTEXT ?????MODEL FORMTEXT ?????BODY STYLE FORMTEXT ?????LICENSE PLATE NUMBER FORMTEXT ?????STATE FORMTEXT ?????DIRECTION OF TRAVEL: (If turning, enter direction BEFORE turn.)ONROUTE(Or Street) FORMCHECKBOX 1 FORMCHECKBOX 2 (See LOCATION Section Above)N FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX APPROXIMATE COST TO REPAIR $ FORMTEXT ????? FORMCHECKBOX Total LossAREA(S) Select Number(s) from Diagram →INITIALDAMAGED: FORMTEXT ?????IMPACT: FORMTEXT ?OTHERDAMAGEDAMAGED PROPERTY OTHER THAN VEHICLES FORMTEXT ????? FORMCHECKBOX ONPAVEMENTOR FORMTEXT ????? FEETOF PAVEMENTEDGEApprox. Damage$ FORMTEXT ?????N FORMCHECKBOX S FORMCHECKBOX E FORMCHECKBOX W FORMCHECKBOX OWNER'S NAME FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????WITNESSName FORMTEXT ?????Address FORMTEXT ?????Telephone Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INSName and Address of Insurance Company -- Vehicle No. 2 (If uninsured, please indicate) FORMTEXT ?????CODESINJURY CLASSIFICATIONFIRST AID BYSEATINGSEAT BELTSEJECTEDK - KilledA - Bleeding Wound, Distorted Member, or Had to Be Carried from Scene.B - Bruises, Abrasions, Swelling, Limping, Etc.C - No Visible Injury But Complaint of Pain or Momentary Unconsciousness.1 - None2 - Police3 - Emergency Medical Technician4 - Doctor5 - Rescue Squad6 - Helicopter Crew7 - Paramedic8 - Unknown123M - MotorcycleB - PedacycleP - PedestrianO - OtherNOTE: Positions 7, 8and 9 indicate Rearof Station Wagon.1 - None Installed2 - Not Used3 - Lab Pelt Only Used4 - Lap and Shoulder Bellts Used5 - Unknown1 - No2 - Yes3 - Partially4 - Unknown456789VEH. NO.1 - OCCUPANT OF YOUR VEHICLE2 - OCCUPANT OF OTHER VEHICLEINJURIESFor each person injured or killed in the accident, use the codes above to fill in the boxes at the right.AGESEXVEH.NO.IN-JURYFIRSTAIDSEATINGSEATBELTSEJECTED1. Name FORMTEXT ?????Address FORMTEXT ????? FORMTEXT ??? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ?DESCRIPTION OF INJURY: FORMTEXT ?????2. Name FORMTEXT ?????Address FORMTEXT ????? FORMTEXT ??? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ?DESCRIPTION OF INJURY: FORMTEXT ?????3. Name FORMTEXT ?????Address FORMTEXT ????? FORMTEXT ??? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ?? FORMTEXT ? FORMTEXT ?DESCRIPTION OF INJURY: FORMTEXT ?????ACCIDENTTYPE1 FORMCHECKBOX Rear End2 FORMCHECKBOX Head On3 FORMCHECKBOX Same Direction Sideswipe4 FORMCHECKBOX Opposite Direction Sideswipe5 FORMCHECKBOX 6 FORMCHECKBOX LEFT & RIGHT TURNSINGLE VEHICLE ACCIDENTACCIDENT OCCURRED FORMCHECKBOX ON FORMCHECKBOX OFF PAVEMENTLEFT TURNS18 FORMCHECKBOX Hit Fixed Object19 FORMCHECKBOX Hit Pedestrian20 FORMCHECKBOX Hit Animal21 FORMCHECKBOX Hit Parked Vehicle22 FORMCHECKBOX Hit Train23 FORMCHECKBOX Ran Off Road24 FORMCHECKBOX Overturned25 FORMCHECKBOX Other7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10 FORMCHECKBOX 11 FORMCHECKBOX 12 FORMCHECKBOX RIGHT TURNS13 FORMCHECKBOX 14 FORMCHECKBOX 15 FORMCHECKBOX 16 FORMCHECKBOX 17 FORMCHECKBOX NARRATIVEDESCRIBE WHAT HAPPENED (Refer to Vehicles by Numbers: State Vehicle = 1, Other Vehicle = 2) FORMTEXT ?????PEDPEDESTRIAN ACTION:Clothing: FORMCHECKBOX Light FORMCHECKBOX Dark1 FORMCHECKBOX Crossing at Intersection2 FORMCHECKBOX Crossing Not at Intersection3 FORMCHECKBOX Walking on Pavement With Traffic4 FORMCHECKBOX Walking on Pavement Facing Traffic5 FORMCHECKBOX Standing on Pavement6 FORMCHECKBOX Playing on Pavement7 FORMCHECKBOX Working on Pavement8 FORMCHECKBOX Other on Pavement9 FORMCHECKBOX Not on PavementENVIRONMENTLIGHTWEATHERROADWAYSURFACEROAD TYPETRAFFIC CONTROLVISION OBSCURED BY1 FORMCHECKBOX Daylight2 FORMCHECKBOX Dark3 FORMCHECKBOX Dark, Arti- ficial Lights4 FORMCHECKBOX Dusk5 FORMCHECKBOX Dawn1 FORMCHECKBOX Clear2 FORMCHECKBOX Cloudy3 FORMCHECKBOX Raining4 FORMCHECKBOX Fog, Smog5 FORMCHECKBOX Snowing or Sleeting6 FORMCHECKBOX Hailing1 FORMCHECKBOX Blacktop2 FORMCHECKBOX Concrete3 FORMCHECKBOX Brick4 FORMCHECKBOX Gravel5 FORMCHECKBOX Dirt6 FORMCHECKBOX Other1 FORMCHECKBOX Stop Sign2 FORMCHECKBOX Traffic Signal3 FORMCHECKBOX Yield Sign4 FORMCHECKBOX Officer, Flagman5 FORMCHECKBOX RR Gates, Signals6 FORMCHECKBOX None7 FORMCHECKBOX Other FORMCHECKBOX YesFUNCTIONING? FORMCHECKBOX No1 FORMCHECKBOX Not Obscured2 FORMCHECKBOX Rain, Snow, Ice on Windshield3 FORMCHECKBOX Trees, Bushes4 FORMCHECKBOX Building(s)5 FORMCHECKBOX Embankment6 FORMCHECKBOX Signboard7 FORMCHECKBOX Hillcrest8 FORMCHECKBOX Parked Vehicle(s)9 FORMCHECKBOX Moving Vehicle(s)10 FORMCHECKBOX Blinding Headlights11 FORMCHECKBOX Blinding Sunlight12 FORMCHECKBOX Other13 FORMCHECKBOX Unknown1 FORMCHECKBOX Dry2 FORMCHECKBOX Wet3 FORMCHECKBOX Snow, Ice4 FORMCHECKBOX Muddy5 FORMCHECKBOX Hazardous MaterialWERE LANES CLEARLY MARKED? FORMCHECKBOX YES FORMCHECKBOX NONUMBEROF LANES: FORMTEXT ??DATE OFTHIS REPORT: FORMTEXT ?????SIGN HERE: FORMTEXT ????? FORMCHECKBOX Operator FORMCHECKBOX Owner ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download