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Please Read Instructions 1 Through 11 On other
Side of Fold Before Completing The inside of
Report.
SECTION A
Report of Accidents.
The driver of a vehicle involved in an accident
resulting in injury to or death of any person, or damage to property
of any one person in excess of five hundred dollars ($500) shall
within ten days after such accident forward a written report of such
accident TO: NJ DEPARTMENT OF TRANSPORTATION, 1035
PARKWAY
AVENUE, CN 600, TRENTON, NJ 08625-0600
ATTN: BUREAU OF TRANSPORTATION DATA AND SAFETY.
Failure
to report will result in the suspension of both driving and
registration privileges. Under Chapter 4 of Title 39 these reports
are not
available
for public information nor are they admissible in
evidence
for any other purpose in a proceeding or action arising
out of the accident. They are solely for the use of the
Department
of
Transportation
in developing
information
useful in the preven-
tion
of accidents and for
compliance
with the Motor
Vehicle Secur-
ity
Responsibility
and
Compulsory
Insurance Laws. “A written
report of an accident shall not be
required
if a law enforcement
officer submits a
written
report of the accident to the division
pursuant to R.S. 39:4-131.”
INSTRUCTIONS
PLEASE PRINT OR TYPE
ALL INFORMATION
USE BLACK OR DARK BLUE INK
Begin by folding along this line
Follow the
instructions
at the top of
Section
B.
Numbered arrows should point to
boxes on reverse side after folding.
1.
Give exact date of
accident.
2. If a vehicle is
unoccupied,
enter all available
information.
Be
sure to enter the correct vehicle plate number.
3. Driver
information
must be
entered
exactly as it
appears
on
each
driver’s
license
.
4.
Owner
information
must
be
entered
exactly as it
appears
on
the registration certificate of each vehicle
involved
in the
accident.
5. If you were involved in an accident in
which there were more
than two
vehicles,
an
additional
one of
these
report forms
must be filled out.
On
that form,
place
the information for
the third
vehicle
in the
space marked
“Your
Vehicle
No.
1”
and mark it No. 3. Use the space marked “Other
Vehicle No.
2
” for the fourth
vehicle,
and mark
it No. 4 and so on.
6.
The location of the accident is very important and you should
describe it as accurately as possible in the space provided.
7.
For each person injured complete boxes 67, 68, 69, 70, 71
and list names and
addresses.
8.
If
there
are more than two persons
injured,
another one
of
these report forms is
needed.
In the injury
section
of that
report,
record
the
required
information for all
additional
injured persons.
9.
Attach any additional report forms to
page
one.
Each
page
of the report must be
numbered
in the
upper
right corner,
dated and
SIGNED
on the bottom line.
10.
Answer all questions to the best of your knowledge.
11.
Send all reports to:
NJ
DEPARTMENT
OF
TRANSPORTATION
1035 PARKWAY AVENUE
PO BOX 600
TRENTON, NJ 08625-0600
ATTN: BUREAU OF TRANSPORTATION
DATA AND SAFETY
SECTION B
REPORT OF MOTOR VEHICLE ACCIDENT
Be sure form is folded along this line before answering the
questions below.
Numbered arrows should point to boxes on reverse side after
folding.
Fill in the 13 boxes to the right by entering the number of
the item which best describes the
circumstances
of the
accident.
If a question does not apply enter a dash (
-
).
If an answer is unknown enter a “U”.
LIGHT CONDITION
DIRECTION OF TRAVEL
WEATHER
VEHICLE POSITION
SURFACE CONDITION
DRIVER
EMPLOYMENT
VEHICLE TYPE
COLLISION
INVOLVED
LOCATION OF FIRST EVENT
1 CLEAR
2 RAIN
3 SNOW
3 DARK (ST LIGHT ON)
4 DARK (ST LIGHT OFF)
5 DARK (NO ST LIGHTS)
1
DAYLIGHT
2
DAWN OR DUSK
3 SNOWY
4 ICY
5 OTHER
1 DRY
2 WET
4 FOG
5 OTHER
1 NORTH
2 EAST
3 SOUTH
4 WEST
1
42
3
S
W
E
N
YOUR
VEHICLE
NO. 1
VEHICLE
NO. 2
YOUR
VEHICLE
NO. 1
OTHER
VEHICLE
NO. 2
YOUR
VEHICLE
NO. 1
OTHER
VEHICLE
NO. 2
YOUR
VEHICLE
NO. 1
OTHER
VEHICLE
NO. 2
1 PASS CAR
-
S
TATION WAGON
2
PASS CAR
W/TRAILER
3 TRUCK
4 TRUCK COMBINATION
5
RECREATION
VEHICLE
6 TAXICAB/LIMOUSINE
FOLD ALONG THIS LINE
7 BUS
8 SCHOOL BUS
9 EMERGENCY VEHICLE
10 MOTORCYCLE
11 OTHER
1 PEDESTRIAN
2 OTHER MOTOR VEHICLE
3 OVERTURNED
4 OTHER NON-COLLISION
5 PEDALCYCLE
6 ANIMAL
7 FIXED OBJECT
8 OTHER OBJECT
1 ON ROADWAY
2 OFF ROADWAY
WAS VEHICLE LEGALLY PARKED AT CURB?
1 YES
2 NO
WAS DRIVER EMPLOYED BY THE VEHICLE OWNER?
1 YES
2 NO
DO NOT FILL IN
FOR USE OF INSURANCE COMPANY ONLY
Instructions for Insurance Company
With regard to an automobile liability insurance policy for the policyholder named on the reverse side hereof, the undersigned insurance company advises
you in
accordance
with the items checked
below:
1. No policy was in effect on the date of the accident.
2. Our policy for the named policyholder applies to him as the operator but it
does
not apply to the owner of the
vehicle
involved
in the accident.
3. Our policy applies to the owner of the vehicle, but does not apply to the operator of the vehicle involved in the accident.
4. Other; explain.
Name of Insurance Company
NJ
DEPARTMENT
OF
TRANSPORTATION
1035 PARKWAY AV
ENUE
PO BOX 600
TRENTON, NJ
08625-0600
ATTN: BUREAU OF TRANSPORTATION
DATA AND SAFETY
MUST be signed by Authorized Representatives
