The driver of a motor vehicle involved in a crash not investigated by a law enforcement officer and resulting in injury to or death of any person, or damage to the property of any one person, including himself, to any apparent extent of at least one thousand dollars ($1,000), must within 10 days after such crash complete and forward this report in accordance with the instructions below.
Section of Form |
Instructions |
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LOCATION |
Complete all data fields to the best of your knowledge; however, fields marked with an |
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asterisk (*) are required data fields and should include sufficient information for TxDOT to |
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process the report. This information is an important element in locating reports and |
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maintaining an accurate filing system. *County or City in the LOCATION portion is |
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required; if this information is not provided, the report will be returned to you. |
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DATE |
*Date of Crash is a required data field and must include the specific month, day, and year |
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the crash occurred. Please provide the time of the crash if known. Only provide one date; if |
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the exact date is unknown, provide the date that the damage was discovered. If the date of |
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the crash is not provided, the report will be returned to you. |
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VEHICLES |
In the portion titled #1 Your Vehicle, the name of the *Driver involved in the crash is a |
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required data field. All remaining information should be completed to the best of your |
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knowledge. In the portion titled #2 Other Vehicle, please specify if the crash involved |
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another motor vehicle, a train, a pedestrian, etc. and provide the name of the other involved |
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party on the line labeled Driver. Please complete the remaining information to the best of |
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your knowledge. |
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DAMAGE TO |
If the crash involved damage to property other than vehicles, please provide all available |
PROPERTY |
information (description of property, location, owner, etc.). |
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INJURIES |
In the portion titled #1 Injured Person, select the position of the occupant in your vehicle |
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that was injured as a result of the crash and complete all data fields on that person. In the |
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portion titled #2 Injured Person, select the position of the other person involved in the crash |
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that was injured and complete all data fields to the best of your knowledge. If known, please |
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indicate if the injured person wore a seatbelt. |
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DRIVER'S |
State Briefly What Happened. In this section please provide a narrative description of the |
STATEMENT |
facts regarding this crash. If space is insufficient, attach a full size sheet of paper for |
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continuation. Please do not send photographs! Photographs cannot be returned. |
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SIGNATURE |
Please review the report to insure accuracy and completeness, as this will expedite the |
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processing of the report and avoid having the report returned for insufficient information. |
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Once you are satisfied with the completeness of the report, sign in black or blue ink and mail |
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to the address at the top of this instruction page. |
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