LONG FORM SHORT FORM UPDATE TOTAL # OF …

1 CRASH DATETIME OF CRASHREPORTING AGENCY CASE NUMBERHSMV CRASH REPORT NUMBERLONG FORMSHORT FORMUPDATEMAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDINGTALLAHASSEE, FL 32399 0537 CRASH IDENTIFIERSCOUNTY CODECITY CODECOUNTY OF CRASHPLACE OR CITY OF CRASHCHECK IF WITHINCITY LIMITSTIME DISPATCHEDTIME REPORTEDTIME ON SCENETIME CLEARED SCENEN otified By: 1 Motorist2 Law Enforcement CHECK IF COMPLETEDREASON (If Investigation NOT Complete)ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS)

2 CRASH OCCURRED ON STREET, ROAD, HIGHWAYAT STREET ADDRESS #1AT LATITUDE AND LONGITUDE2 FEETMILESN S E WAT / FROM INTERSECTION WITH STREET, ROAD, HIGHWAY3OR FROM MILEPOST #4 Road System Identifier1 Interstate2 State4 County5 Local6 Turnpike/Toll7 Forest Road8 Private Roadway9 Parking Lot77 Other, Explain in NarrativeType of Shoulder1 Paved2 Unpaved 3 CurbType of Intersection1 Not at Intersection2 Four Way Intersection3 T Intersection4 Y Intersection5 Traffic Circle6 Roundabout7 Five Point, or More77 Other, Explain in Narrative CRASH INFORMATION (CHECK IF PICTURES TAKEN) TOTAL # OF vehicle SECTION(S) _____TOTAL # OF PERSON SECTION(S) _____TOTAL # OF NARRATIVE SECTION(S)

3 _____Light Condition1 Daylight2 Dusk3 Dawn4 Dark Lighted5 Dark Not Lighted6 Dark Unknown Lighting77 Other, Explain in Narrative88 Unknown4 Fog, Smog, Smoke5 Sleet/Hail/Freezing Rain6 Blowing Sand, Soil, Dirt7 Severe Crosswinds77 Other, Explain in NarrativeWeather Condition1 Dry 2 Wet4 Ice/Frost 5 Oil6 Mud, Dirt, Gravel7 Sand8 Water (standing/moving) 77 Other, Explain in Narrative88 UnknownRoadway Surface Condition1 No2 Yes, School Bus Directly Involved3 Yes, School Bus Indirectly Involved School Bus Related1 Front to Rear2 Front to Front3 Angle4 Sideswipe, Same Direction5 Sideswipe, Opposite Direction6 Rear to Side7 Rear to Rear77 Other.

4 Explain in Narrative88 Unknown Manner of Collision/Impact First Harmful Event First Harmful Event within Interchange1 No 2 Yes 88 Unknown1 Overturn/Rollover2 Fire/Explosion3 Immersion4 Jackknife 5 Cargo/Equipment Loss or Shift6 Fell/Jumped From Motor Vehicle7 Thrown or Falling Object8 Ran into Water/Canal9 Other Non Collision10 Pedestrian11 Pedalcycle12 Railway vehicle (train, engine)13 Animal14 Motor vehicle in Transport15 Parked Motor Vehicle16 Work Zone/Maintenance Equipment17 Struck By Falling, Shifting Cargo18 Other Non Fixed ObjectNon-CollisionCollision Non-Fixed ObjectCollision with Fixed Object19 Impact Attenuator/Crash Cushion20 Bridge Overhead Structure21 Bridge Pier or Support22 Bridge Rail 23 Culvert 24 Curb25 Ditch26 Embankment 27 Guardrail Face28 Guardrail End 29 Cable Barrier30 Concrete Traffic Barrier31 Other Traffic Barrier32 Tree (standing)

5 33 Utility Pole/Light Support34 Traffic Sign Support35 Traffic Signal Support36 Other Post, Pole or Support37 Fence 38 Mailbox39 Other Fixed Object (wall, building, tunnel, etc.)First Harmful Event Location1 On Roadway2 Off Roadway3 Shoulder4 Median6 Gore7 Separator8 In Parking Lane or Zone9 Outside Right of way10 Roadside88 Unknown1 Non Junction2 Intersection3 Intersection Related4 Driveway/Alley Access RelatedFirst Harmful Event Relation to Junction5 Railway Grade Crossing14 Entrance/Exit Ramp 15 Crossover Related16 Shared Use Path or Trail17 Acceleration/Deceleration Lane18 Through Roadway77 Other, Explain in Narrative88 UnknownContributing Circumstances.

6 Road1 None4 Work Zone (construction/ maintenance/utility) 6 Shoulders (none, low, soft, high)7 Rut, Holes, Bumps 9 Worn, Travel Polished Surface10 Road Surface Condition (wet, icy, snow, slush, etc.) 11 Obstruction in Roadway12 Debris13 Traffic Control Device Inoperative, Missing or Obscured14 Non Highway Work 77 Other, Explain in Narrative88 UnknownContributing Circumstances: Environment 1 None 2 Weather Conditions3 Physical Obstruction(s)4 Glare 5 Animal(s) in Roadway 77 Other, Explain in Narrative88 UnknownWork Zone Related1 No2 Yes 88 Unknown 1 Before the First Work Zone Warning Sign2 Advance Warning Area 3 Transition Area4 Activity Area5 Termination AreaCrash in Work Zone1 Lane Closure2 Lane Shift/Crossover3 Work on Shoulder or Median4 Intermittent or Moving Work77 Other.

7 Explain in NarrativeType of Work Zone1 No 2 Yes88 Unknown Workers in Work ZoneLaw Enforcement in Work Zone1 No2 Officer Present3 Law Enforcement vehicle Only PresentWITNESSESNAME ADDRESS CI TY & STATE ZIP CODEVEHICLE # vehicle #NON vehicle PROPERTY DAMAGEPROPERTY DAMAGE OTHER THAN VEHICLEEST. AMOUNTOWNER S NAME (Check if Business) ADDRESS CITY & STATE ZIP CODEPROPERTY DAMAGE OTHER THAN VEHICLEEST.

8 AMOUNTOWNER S NAME (Check if Business) ADDRESS CITY & STATE ZIP CODENAME ADDRESS CI TY & STATE ZIP CODENAME ADDRESS CI TY & STATE

9 ZIP CODEPage ___ of ___1 Clear2 Cloudy3 RainDATE OF REPORTPERSON #PERSON #HSMV 90010 S (E) (rev 06/13) vehicle # Check if CommercialREPORTING AGENCY CASE NUMBERHSMV CRASH REPORT NUMBERVIOLATIONSVEHICLE N S E W Off Road Unknown ON STREET, ROAD, HIGHWAYTRAVELINGHAZ. MAT. RELEASED1 No 2 Yes 88 Unknown1 vehicle in Transport2 Parked Motor Vehicle3 Working vehicle vehicle LICENSE NUMBERSTATE REGISTRATION EXPIRES Check if PermanentRegistrationVINHit and Run1 No 2 Yes88 UnknownYEARMAKEMODELSTYLECOLORDAMAGE: 1 Disabling 4 Minor2 Functional 88 Unknown 3 None EST.

10 AMOUNTINSURANCE COMPANY INSURANCE POLICY NUMBERT owed dueto Damage:1 No 2 YesVEHICLE REMOVED BY1 Rotation 2 Owner Request3 Driver 77 Other, Explain in NarrativeNAME OF vehicle OWNER (Check if Business) CURRENT ADDRESS CITY & STATE ZIP CODESTATE TRAILER # LICENSE NUMBERREGISTRATION EXPIRESC heck if PermanentRegistrationVINYEARMAKELENGTHAX LESREGISTRATION EXPIRESC heck if PermanentRegistrationVINYEARMAKELENGTHAX LESTOTAL LANESPOSTED SPEEDAT EST.