DMV 349 Crash Report

0 None 0 None
.--
DMV-349 (Rev. 1/2009)
r
THIS REPORT IS FOR THE USE OF THE DIVISION OF MOTOR VEHICLES. THE DATA IS COLLECTED FOR
STATISTICAL ANALYSIS AND SUBSEQUENT HIGHWAY SAFETY PROGRAMMING. DETERMINATIONS OF
"FAULT" ARE THE RESPONSIBILITY OF INSURERS OR OF THE STATE'S COURTS.
D
D
Form
of
0
Supplemental Report
County
Crash Date
D
D
Roadway Sll'face __ occurred
L
0
c
1 Dry
A
T
I
0
~
s
--
0
VEHICLE
0
Driver
PEDESTRIAN
0
HIT&RUN
_J_
0
w
ODDO
ft. N
(0 fl-lnl«saction)
s
w
E
(If available)
Longilude
Use Highway Number, Street Name or Adjacent County or State Line
UNIT#
-- 0VEHICLE
Altitude
0PEDESTRIAN 0HIT & RUN 00THER
D
D
Non-Collision
Driver
_J_
Last
Suffix
First
Mddle
Last
Suffix
Address
Address
0 None (no unusual cond
0 None (no unusual cond
1---i
Driver's
H(
Phone
Numbers W(
License? 0 Yes 0 No
D.L. #
DOB
mm/dd/ccyy
37 Alcohol/
Drugs Suspected
State _ _ Zip
City
)
Same Address on Driver's
)
License? 0 Yes 0 No
D.L.
Class
0 None
COL License 0
0 No
outside municipality
w
Miles
l-·--
toward
COMMERCIAL
20 VEHICLE
..L
Mddle
First
E
Latitude
s
Use Highway Number, Street Name or Adjacent County or State Line
UNIT#
D
D
DODO
(RR.Crossing#
DODO
N
E
at or from
Same Addrass on Driver's
1 Daylight
0
Ramp or
Service Road
1-----"
Non-Collision
o r _ , _ _ Miles N
Highway Number, or Highway, Street (If ramp or service road, indicate on line)
.____., City
1 Yes
In
Near
Date Received by OMV
Local Use/Patrol Area
Municipality
1 Clear
r-
J2!.Hnur Clock\
on
N
1 Clear
El
Non-Reportable
I
Time
1 Farms, woods, pastures
1 On Roadway (Surface)
33 Relation to
Crash
0
8
~
CLEAR FORM
1 Rural (<30% developed)
No. of Units Involved
0
Do not write in these spaces
State _ _ _
1 Apparently normal
DL#
COL License
34 Vision
35 Physical
36 D.L.
Obstruction _ _ _ Condition _ _ _ Restrictions
DOB
0 No test
0 No
0 No Test
36 Alcohol/
Drugs Test
39 Results
(if known)
I
I
40 Vehicle
Seizure (DWI) 0
1
State _ _ Zip
Driver's
H(
Phone
Numbers W(
0
mm/dd/ccyy
)
DL
Class
0 None
State_ _ _ t----'
1 Apparently normal
0 No contributing circums
~
34 Vision
35 Physical
36 D.L.
Obstruction _ _ _ Condition _ _ _ Restrictions
0 No test
37 Alcohol/
Drugs Suspected
~
)
0 No Test
38 Alcohol/
Drugs Test
39 Results
(if known)
I
I
40 Vehicle
Seizure (DWI) 0
0 No contributing circums
r--;-1
0 No contributing circums
Owner
Owner
I
Same as Driver? 0
Same as Driver? 0
Address
Address
Same Address as Driver? 0 ,
State _ _ Zip
Plate#
VIN
42 Vehicle 0
Drivable 0
41 Vehicle
Style [Type)
Yes
No
44 Estimated
43 TAD
Plate
Plate
State - - Year
Plate #
VIN
1 Passenger car
Vehicle
Year
State _ _ Zip
City
Plate
Plate
State - - Year
Vehicle
Make
Vehicle
Year
43 TAD
Policy#
20 COMMERCIAL VEHICLE: Cargo, Carrier Name, Address, Source
Source:
Carrier Identification Numbers, GVWR, Axles
0
Truck
US DOT# _ _ _ _ _ _ ICC#
-
0
Shipping
papers
State _ _
Same Address as Owner?
D
24
23
25
26
27
28
29
30
31
Unit1-0rv1, Ped1,eto.
A
ma.
t--
Driver
-
State#
-
-
-
-
IFTA#
FE!#
Fleet#
Axles on Vehicle
Including Trailers
--------
Gross Vehicle
Weight Rating
Names and Addresses for All Persons (Unit 1/Unit 2 Orv, Ped, etc. - See Above); Use check blocks if address same as Driver
_.above_
see
---
c
32
see
_J_
1Jni12-0rv2, Ped2,eto.
B
1-------jg
Damage
Policy#
D
Yes
No
44 Estimated
Insurance
Company
7 Flatbed
0 No contributing circums
42 Vehicle 0
Drivable 0
41 Vehicle
Style [Type)
Damage
Unit___ 45 Cargo Body Type _ _ _
0 No contributing circums
t---;a
1 Passenger car
Vehicle
Make
Insurance
Company
22
t-0 No contributing circums
t-1
Same Address as Driver? 0
City
21
t---;a
I
Veh#_ Towed To/By:
Veh# _Towed
To/By:
tl
D
_J_
_J_
_J_
E
b
b_
F
G
_J_
-
b_
_J_
.J.
H
tl
·""··w
-
-
b_
47 Injured Taken _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
by EMS to
(Treatment Facility and City or Town)
47 Injured Taken _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
by EMS to
(Treatment Facility and City or Town)
_J
48 POINTS OF INITIAL
CONTACT
{Vi\ite in Codes)
VEHICLE INFO.
Unit#_
Unit#
(Unit Level)
CRASH SEQUENCE
Unit#_
Unit#_
Veh.#_
ROADWAY INFO.
Veh.#_
WORK ZONE RELATED
60 Authorized Speed Limit
69 Road
Road
Feature
69
Feature
78 Workzone Area
61 Estimate of Original Traveling Speed
70 Road
Character
70
Road Character
79 Work Activity
so Work Area Marked
49
Vehicle
Manuver/Action
49 Vehicle
Maneuver/Action
62
50
Non-Motorist
50 Non-Motorist
Action Action
63 Tire Impressions Before Impact (fl.)
72
Road Surface
SurfaceType
Type
72 Road
51
Non-Motorist
Location
to Impact
51 Non·Motorist
location
Prior Prior
to Impact
64 Distance Traveled After Impact (fl.)
73
73 Road
Road Configuration
Configuration
52
First Harmful
- Vehicle
Level
52 Crash
Sequence Event
• First Event
for This
Unit
65 Emergency Vehicle Use
74
Access
Control
74 Access
Control
82 Trailer Type
53 Crash Sequence - Second Event
66 Post Crash Fire (if 'Yes' check block)
75 Number of Lanes
1st Trailer No. Axles
54 Crash Sequence - Third Event
67 School Bus - Contact Vehicle
55 Crash Sequence - Fourth Event
68 School Bus - Noncontact Vehicle
71 Road
71
Road Classification
Classification
Estimate of Speed at Impact
D
D
D
D
D
D
D Yes D No
Hazardous cargo D Yes D No
Haz Mat Placard
57
Distance/Direction
to Object
57 Distance/Direction
to Object
Struck Struck
58
Vehicle
Underride/Override
58 Vehicle
Underride/Override
Carrying Haz Mat
Unit#_
Length (feet)
77
Control
Operating
77 Traffic
Traffic
Control
Ope
0
2nd Trailer No. Axles
Width (Inches)
Length (feet)
4--0igit placard number or
1-<ligit number from
name from diamond or box bottom of diamond
D Yes D No
Unit#_
Width (inches)
From Placard indicate:
Released (does not incb1e fuel from fuel tank)
59
Vehicle
Defects
59 Vehicle
Defects
TRAILER INFO.
76
76 Traffic
TrafficControl
ControlType
Type
COMMERCIAL VEHICLE: Hazardous Materials Involvement Unit__
56 Most Hanmful Event for This Unit
a1 Crash location
----
64DIAGRAM Vehicles Moved YES
Overwidth Permit#
83 Unit# _
Overwidth Trailer
and Overwidth
-
MnhiiA HnmA
I
I
I
I
I
I
I
I
Vehicles Moved NO
Indicate
North
U
Unit.#_ was:
ss NARRATIVE
.
Traveling
D Parked Facing DODD
N S E W
on
Unit.#_ was:
IT Traveling D D D D
D Parked Facing N S E W
on
(Include pertinent and unUS<1al aspects,
""1ich '"'" not istsd elsewhere on the loon)
Owner Address
Phone
86 Type/
Owner
Stats
Property?
ADDITIONAL PROPERTY DAMAGE
D
WITNESSES
Name
Address
Name
Address
Phone No.
(
Phone No.
(
__
Estimated $
D...nage
)
)
TRAFFIC VIOLATION(S)
Charge(s)
Name
(Citation # optional)
Charge(s)
Name
Officer Name
Officer Number
Department
Date of Report
Print
<<< Click to print. For Exchange Forms only, set pages to 3 and/or 4.
DRIVER EXCHANGE FORM
Driver
North Carolina Division of Motor Vehicles
Request for Motor Vehicle Information
Crash
Address
Crash Date
City
County
State
I hereby request a copy of a crash report:
Zip
Same Address on Driver’s License?
Yes
No
Requestor:
Driver
Driver’s Phone
Numbers
H
W
Driver Lic. No.
DL#
DL Class
DL State
Vehicle Owner
DOB
Plate No.
Name:
First
MI
Last
Suffix
Owner
Address:
Same as Driver?
Address
Address
Same Address as Driver?
City
City
State
State
Zip
Zip
I am qualified to obtain this information for my own
personal record:
Plate #
Plate State
Signature:
Plate Year
Date Requested:
VIN
Vehicle
Make
Vehicle
Year
For Cost or Fees contact the Crash Reports Unit at
919-861-3068 or visit the Traffic Records Website
http://www.ncdot.org/dmv/forms/ click “Crash
Report Request Form (TR-67A)”
Insurance
Company
Make Checks payable to NCDMV
Policy #
Date of Crash
Officer Name
County
Non-Reportable
Local Report Number
Mail Request to DMV – Crash Reports Unit,
3105 Mail Service Center
Raleigh, NC 27699-3105
DRIVER EXCHANGE FORM
Driver
North Carolina Division of Motor Vehicles
Request for Motor Vehicle Information
Crash
Address
Crash Date
City
County
State
I hereby request a copy of a crash report:
Zip
Same Address on Driver’s License?
Yes
No
Requestor:
Driver
Driver’s Phone
Numbers
H
W
Driver Lic. No.
DL#
DL Class
DL State
Vehicle Owner
DOB
Plate No.
Name:
First
MI
Last
Suffix
Owner
Address:
Same as Driver?
Address
Address
Same Address as Driver?
City
City
State
State
Zip
Zip
I am qualified to obtain this information for my own
personal record:
Plate #
Plate State
Signature:
Plate Year
Date Requested:
VIN
Vehicle
Make
Vehicle
Year
For Cost or Fees contact the Crash Reports Unit at
919-861-3068 or visit the Traffic Records Website
http://www.ncdot.org/dmv/forms/ click “Crash
Report Request Form (TR-67A)”
Insurance
Company
Make Checks payable to NCDMV
Policy #
Date of Crash
Officer Name
County
Non-Reportable
Local Report Number
Mail Request to DMV – Crash Reports Unit,
3105 Mail Service Center
Raleigh, NC 27699-3105

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