Fillable INSTRUCTIONS FOR COMPLETING STATE OF WASHINGTON MOTOR VEHICLE

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INSTRUCTIONS FOR COMPLETING STATE OF WASHINGTON MOTOR VEHICLE

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3000-345-161 (R 1/15)
INSTRUCTIONS FOR COMPLETING
STATE OF WASHINGTON
MOTOR VEHICLE COLLISION REPORT
Any driver, pedestrian, pedalcycle, or property owner involved in a collision within this state—with $1,000.00 or more damage to
any one unit and/or injury to any person—must complete a Motor Vehicle Collision Report. Mail this report to the
Washington State Patrol, Collision Records Section, PO Box 42628, Olympia, WA 98504-2628.
However, if a police officer is present and indicates he/she will submit a collision report, you are not required to submit one.
Completing online version: (www.wsp.wa.gov, search for “Collision Reporting,” then scroll down to “Citizen Reports”)
Print this document single-sided, not double-sided, upon completion.
Retain a copy for your records.
Completing printed version:
Print using a black ball-point pen—do not use a pencil or felt-tip pen.
Keep the carbon copy for your records.
When information is not applicable or available: Leave that portion of the form blank.
Submitting online or printed version: Mail to address above; neither version can be e-mailed or faxed.
NOTE: A “unit” is a motor vehicle, pedestrian, pedalcycle, and/or a property owner. You, as the involved party, will
always be Unit 1.
Report Number
This is an auto-generated number. Leave this field blank.
Date of Collision
Date collision occurred. If the date of the collision is unknown, use the date the damage was
discovered (mandatory field).
Day of Collision
Check the appropriate box.
Time of Collision
Time collision occurred or time the damage was noticed (check a.m. or p.m. box).
Investigated By
Check the appropriate box for the law enforcement agency that investigated the collision OR
indicate “No Investigation” if law enforcement did not investigate.
Collision Involved
Check the appropriate box if any of the following apply: Vehicle Fire/Hit & Run/Stolen Vehicle.
Indicate Total # of Units (vehicles/parties involved), Total # Injuries, Total # Deaths.
Place Where Collision
Occurred
COUNTY: The county where the collision occurred. If unknown, use the county where the
damage was discovered (mandatory field).
CITY OR TOWN: The city or town where the collision occurred.
Road Surface
Check the appropriate box(es) for the road surface conditions at the time of the collision.
Weather
Check the appropriate box(es) for the weather conditions at the time of the collision.
Light Conditions
Check the appropriate box(es) for the light conditions at the time of the collision.
Location of Where
Collision Occurred
Identify the name of the street/highway you were on or the address or name of the parking lot.
Example:
Interstate – I-5, I-82, I-205, or I-705 State Route – SR-20, Highway 99, SR-101
City Street – a street or road within the city County Road – a street or road outside the city
Other – parks, campus, forest service road, Private Way – private road, shopping mall,
military base parking lot, driveway
Distance From
Indicate the distance from the street or location indicated under “Location of Where Collision
Occurred” and check the appropriate boxes for feet/miles and direction.
Example: 3.0 miles north or 200 feet east
Nearest Street or Land
Mark
Indicate the nearest street or land mark to the collision location.
Example: Exit 120, Capital Mall, Linderson Way SW, 3.0 miles north of 22nd Avenue, and/or 200
feet east of Capital Mall
Was Driver Distracted
Check the appropriate box and indicate what the distraction was (if more room is needed, attach
additional blank pages or use additional Was Driver Distracted pages).
Describe Below What
Happened
Refer to the vehicles as units and explain to the best of your knowledge what occurred (if more room
is needed, attach additional blank pages or use additional Describe Below pages).
At Moment of Collision
Identify each unit and check the appropriate box to indicate if the unit was parked/stopped/moving.
Diagram
Draw a picture of roadway/intersection/parking lot, etc. Show your unit (vehicle)/others involved.
Witness Name
List names, addresses, and phone numbers of any witnesses (if more room is needed, attach
additional blank pages or use additional Witness pages).
Signature/Date of
Report
The person completing the form must sign and date the form and provide his or her address. The
signature is a legal requirement (mandatory field).
W
HEN TO COMPLETE AND SUBMIT
BEFORE YOU BEGIN, THINGS TO KNO
W
W
HAT WE ARE REQUESTING IN SPECIFIC FIELDS
NOTE: Certain portions of this form
cannot be completed electronically.
SPECIAL NOTE:
Please print this document single-
sided, not double-sided.
3000-345-161 (R 1/15)
Unit
The person completing the report should be Unit 1. Unit 2 is the other party involved. If more
parties are involved, attach additional blank pages or use additional Units Involved pages. A
unit may be a motor vehicle (motorcycle, etc.), pedalcycle (bicycle, tricycle, unicycle), pedestrian
(wheelchairs, skateboards, and roller skates), or property owner (fence, yard, trees, ditch, etc.)
that had damage. If you are a property owner, enter in the name, address, and estimated cost
for repair. Check the appropriate box to indicate if you are a motor vehicle, pedalcycle,
pedestrian, or property owner.
Was Helmet Used
Check the appropriate box to indicate if a helmet was used if you were a motorcyclist,
pedalcyclist, skater, or skateboarder.
Name
Provide your full last name, full first name, and middle initial.
Sex
Check the appropriate box.
Address
Provide your full address and/or a mailing address (check the box if this is a new address), city,
state, and ZIP code.
Driver’s License #
Provide your driver’s license number.
State
Indicate the state that issued your driver’s license.
Date of Birth
Provide the month, date, and year you were born.
License Plate/State
Provide your license plate number and the state where the vehicle is registered.
VIN
Provide the Vehicle Identification Number. It can be 10 to 17 characters long (found on the
vehicle registration or on your insurance card).
Trailer Plate #
If you were pulling a flatbed, camping trailer, etc., provide the license plate number and state.
Estimated Cost to
Repair Vehicle or
Ob
j
ect Struck
Estimate the cost to fix your vehicle or the object struck.
Vehicle Year
Provide the year of your vehicle.
Make
Provide the make (i.e., Ford, Chevrolet, Dodge, etc.).
Model
Provide the model (i.e., Taurus, Lumina, Charger, etc.).
Body Style
Provide the body style (i.e., 2 door, 4 door, hatchback, etc.).
Registered Owner
Provide the full name, address, state, and ZIP code of the registered owner.
Was Auto Liability
Insurance in Effect at
Time of the Collision
Check the appropriate box.
Insurance Compan
y
and Polic
Numbe
Provide the name of your insurance company and policy number.
Nature of Injuries
Indicate the type of injuries, if any (head pain, chest pain, legs hurt, etc.).
Mark if This Unit Was
a Commercial Vehicle
Indicate if this was a commercial vehicle. Types of commercial vehicles may include cement
truck, semi with attached trailer, school bus (vehicle with a gross vehicle weight rating [GVWR]
of more than 26,000 pounds).
Shade In Damaged
Area of Vehicle
Shade in the area where damage occurred on the vehicle.
Passengers
Identify passengers by the unit number they belong to (i.e., Unit 1, Unit 2, etc.). If there were
more than two passengers, use an additional Units Involved page for other passengers.
Complete the passenger fields as follows:
Name
Provide the full last name, full first name, and middle
initial.
In Unit #
Indicate which unit they were in (i.e., Unit 1, Unit 2, etc.).
Sex
Check the appropriate box.
Address
Provide full address and/or mailing address including city,
state, and ZIP code.
Date of Birth Provide the month, day, and year they were born.
Nature of Injuries
Indicate the type of injuries incurred.
If Motorcyclist or Pedalcyclist
Was Helmet Used
Check the appropriate box.
W
HAT WE ARE REQUESTING IN SPECIFIC FIELDS (continued)
STATE OF WASHINGTON
VEHICLE
COLLISION
REPORT
DATE OF COLLISION
NAME OF STREET/HIGHWAY YOU WERE ON OR ADDRESS/NAME OF PARKING LOT:
____________________________________________________________________________________
DISTANCE FROM ______ . ______ in FEET MILES N E S W
NEAREST STREET OR LAND MARK (BRIDGE, RR CROSSING, OTHER LAND MARK):
____________________________________________________________________________________
WAS DRIVER DISTRACTED
UNIT #____
YES NO
UNIT #____ YES NO
DISTRACTIONS INCLUDE: OPERATING A
TELECOMMUNICATION DEVICE, ELECTRONIC
DEVICES, PDA, LAPTOP COMPUTER, NAVIGATION
DEVICES, ADJUSTING AN AUDIO OR ENTERTAINMENT
SYSTEM, SMOKING, INSIDE DISTRACTIONS, OUTSIDE
DISTRACTIONS, EATING OR DRINKING, ANIMALS,
PASSENGERS, ETC.
DISTRACTED BY: ___________________________________
LOCATION OF WHERE COLLISION OCCURRED:
DESCRIBE BELOW WHAT HAPPENED (REFER TO UNITS BY NUMBER)
DIAGRAM
DAY OF COLLISION TIME OF COLLISION COLLISION INVOLVEDINVESTIGATED BY:
PLACE WHERE COLLISION OCCURRED
M M D D Y Y Y Y
HOUR MINUTES
AM
PM
VEHICLE FIRE HIT & RUN STOLEN VEHICLE
TOTAL #
UNITS
TOTAL #
INJURIES
TOTAL #
DEATHS
ROAD SURFACE WEATHER LIGHT CONDITIONS
DRY
SAND/MUD
WET
OIL
SNOW
STANDING
WATER
ICE
OTHER
CLEAR/PTLY
CLOUDY
FOG
OVERCAST
SLEET
RAINING
SEVERE
CROSSWIND
SNOWING
OTHER
DAYLIGHT
DARK-STREET
LIGHTS ON
DAWN
DARK-STREET
LIGHTS OFF
DUSK
DARK-NO
STREET LIGHTS
OTHER
AT MOMENT OF COLLISION: UNIT #____
PARKED UNOCCUPIED
PARKED OCCUPIED
STOPPED
MOVING
AT MOMENT OF COLLISION: UNIT #____
PARKED UNOCCUPIED
PARKED OCCUPIED
STOPPED
MOVING
SUN MON TUE WED THU FRI SAT
COUNTY
CITY OR
TOWN
REPORT NO.
SHOW NORTH BY ARROW IN CIRCLE
STREET OR HIGHWAY _______________________
STREET OR
HIGHWAY _____________
INDICATE ON THIS DIAGRAM
WHAT HAPPENED
1. TRACE THE OUTLINE THAT REFLECTS YOUR
COLLISION SCENE, WRITING IN STREET OR
HIGHWAY NAMES.
2. NUMBER EACH UNIT AND SHOW DIRECTION
OF TRAVEL BY ARROW
1 2
(OFFICIAL USE ONLY)
UNIT #____ WAS ON-DUTY LAW
ENFORCEMENT OR FIREFIGHTER
(RCW 41.26.030)
WITNESS NAME ADDRESS PHONE NUMBER
1
WITNESS NAME ADDRESS PHONE NUMBER
2
SIGNATURE OF PERSON COMPLETING REPORT ADDRESS
X
MAIL TO: WASHINGTON STATE PATROL, RECORDS SECTION, PO BOX 42628, OLYMPIA, WA 98504-2628
DATE OF REPORT
MO. DAY YEAR
PAGE OF
M M D D Y Y Y Y
UNITS = MOTOR VEHICLE, PEDESTRIANS, PEDALCYCLE AND/OR PROPERTY OWNER
STATE PATROL
CITY POLICE
SHERIFF
OTHER POLICE
NO INVESTIGATION
3000-345-161 (R 1/15)
1 1
2
1
SPECIAL NOTE:
Please print this document
single-sided, not double-sided.
RESET
(Clears all Fields in the Form)
REPORT NO.UNITS INVOLVED
PASSENGERS
UNIT #______
(MARK ONLY ONE)
MOTOR
VEHICLE
PEDAL-
CYCLE
PEDESTRIAN
PROPERTY
OWNER
WAS HELMET USED BY MOTORCYCLIST, PEDALCYCLIST,
SKATER, SKATEBOARDER?
UNIT #______
(MARK ONLY ONE)
MOTOR
VEHICLE
PEDAL-
CYCLE
PEDESTRIAN
PROPERTY
OWNER
WAS HELMET USED BY MOTORCYCLIST, PEDALCYCLIST,
SKATER, SKATEBOARDER?
LAST NAME IN UNIT
LAST NAME IN UNIT
FIRST NAME
MIDDLE
INITIAL
SEX M F
FIRST NAME
MIDDLE
INITIAL
SEX M F
NATURE OF INJURIES
IF MOTORCYCLIST OR PEDALCYCLIST WAS
HELMET USED?
Y N
NATURE OF INJURIES
IF MOTORCYCLIST OR PEDALCYCLIST WAS
HELMET USED?
Y N
ADDRESS
D.O.B.
MM-DD-YYYY
M M D D Y Y Y Y
ADDRESS
D.O.B.
MM-DD-YYYY
M M D D Y Y Y Y
YES NO
YES NO
LAST NAME
FIRST NAME
MIDDLE
INITIAL
SEX M F
CITY
ST ZIP
LICENSE
PLATE #
STATE VIN
TRAILER
PLATE #
STATE
ESTIMATED COST TO REPAIR VEHICLE
OR OBJECT STRUCK
$
.00
VEH YEAR MAKE (CHEV, FORD) MODEL (CAMARO, TAURUS) BODY STYLE (2 DR)
REGISTERED OWNER (LAST - FIRST - MIDDLE INITIAL) OWNER’S ADDRESS (STREET, CITY, STATE & ZIP CODE)
WAS AUTO LIABILITY INSURANCE IN
EFFECT AT TIME OF THE COLLISION?
YES NO
INSURANCE COMPANY AND POLICY NUMBER
DRIVER’S
LICENSE #
STATE
D.O.B.
MM-DD-YYYY
M M D D Y Y Y Y
ADDRESS
NEW
LAST NAME
FIRST NAME
MIDDLE
INITIAL
SEX M F
CITY
ST ZIP
LICENSE
PLATE #
STATE VIN
TRAILER
PLATE #
STATE
ESTIMATED COST TO REPAIR VEHICLE
OR OBJECT STRUCK
$
.00
VEH YEAR MAKE (CHEV, FORD) MODEL (CAMARO, TAURUS) BODY STYLE (2 DR)
REGISTERED OWNER (LAST - FIRST - MIDDLE INITIAL) OWNER’S ADDRESS (STREET, CITY, STATE & ZIP CODE)
WAS AUTO LIABILITY INSURANCE IN
EFFECT AT TIME OF THE COLLISION?
YES NO
INSURANCE COMPANY AND POLICY NUMBER
DRIVER’S
LICENSE #
STATE
D.O.B.
MM-DD-YYYY
M M D D Y Y Y Y
ADDRESS
NEW
1 5
2
8
3
9 TOP
10 BOTTOM
7
4
6
1 5
2
8
3
9 TOP
10 BOTTOM
7
4
6
NATURE OF INJURIES
MARK IF THIS UNIT WAS
A COMMERCIAL VEHICLE
VEHICLE
SHADE IN DAMAGED AREA
NATURE OF INJURIES
MARK IF THIS UNIT WAS
A COMMERCIAL VEHICLE
VEHICLE
SHADE IN DAMAGED AREA
3000-345-161 (R 1/15)
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INSTRUCTIONS FOR COMPLETING STATE OF WASHINGTON MOTOR VEHICLE

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Completed 26 March 2022

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