State of Nebraska Investigator’s Motor Vehicle Accident Report€¦ · Seat Eject Body Injury...
5
YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE TOTALED $ NAME ADDRESS / / LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO. NAME ADDRESS / / LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO. NAME ADDRESS / / LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO. ONE-WAY YES NO STREET? LONGITUDE LATITUDE OF NEAREST STREET, BRIDGE, RAILROAD CROSSING FEET MILES IF NOT AT INTERSECTION N S E W N S E W IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN NAME OF INTERSECTING ROADWAY IF AT INTERSECTION PRIVATE YES NO PROPERTY? Total Number of Vehicles DATE OF ACCIDENT PLACE OF ACCIDENT ROAD ON WHICH ACCIDENT OCCURRED R. WORK ZONE CODES S. PEDESTRIAN CLASSIFICATION CODES DOES ACCIDENT INVOLVE DAMAGE TO STATE DEPT. OF ROADS’ PROPERTY? YES NO DISTANCE FROM MILEPOST COUNTY CITY STREET/ HIGHWAY NO. FEET MILES AND MILES OF NEAREST CITY OR TOWN OF MILEPOST HIGHWAY NO. STATE USE ONLY INVESTIGATION MADE AT SCENE? HIT & RUN? Local No./ District Agency Case No. M M / D D / Y Y Y Y S M T W TH F S N S E W R1 R2 R3 R4 N S E W TIME OF ACCIDENT POLICE NOTIFIED State of Nebraska Investigator’s Motor Vehicle Accident Report S1 S2 S3 S4 S5-a S5-b S6-a S6-b (In Military Time) YES NO YES NO Sheet _____ of _____ DR Form 40, Jan 09 THIS FORM REPLACES DR FORM 40, JAN 02 PREVIOUS EDITIONS WILL BE DESTROYED. A/1 A/2 B C D V1/M V2/M E F V1/N V2/N G H V1/O V2/O I V1/P V2/P J V1/Q V2/Q K CITATION YES PENDING NO STATE (Of License) DATE OF BIRTH (MM / DD / YYYY) LICENSE PLATE VEHICLE NO. 1 YEAR (Plate Expires) DRIVER LICENSE NO. DRIVER DRIVER ADDRESS CITY, STATE, ZIP OWNER PHONE – PHONE – LOCAL NO. LOCAL NO. CITATION NO. OWNER ADDRESS CITY, STATE, ZIP VEHICLE ID NO. (VIN) TOWED TO TOWED BY VEHICLE NO. STATE (Of Plate) SEX FEMALE MALE INSURANCE COMPANY POLICY NO. / / CITATION YES PENDING NO STATE (Of License) DATE OF BIRTH (MM / DD / YYYY) LICENSE PLATE VEHICLE NO. 2 YEAR (Plate Expires) DRIVER LICENSE NO. DRIVER DRIVER ADDRESS CITY, STATE, ZIP OWNER PHONE – PHONE – LOCAL NO. LOCAL NO. CITATION NO. OWNER ADDRESS CITY, STATE, ZIP VEHICLE ID NO. (VIN) TOWED TO TOWED BY VEHICLE NO. STATE (Of Plate) SEX FEMALE MALE YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE TOTALED $ INSURANCE COMPANY POLICY NO. / / 1 2 3 4 5 SEX Seat Eject Body Injury Trans. M F Position Region Sev. Complete this section for all injured persons (Complete a continuation report, if more than three were injured) VEH. # VEH. # VEH. # DATE OF BIRTH (MM / DD / YYYY) L V1/1 V1/2 V1/3 V1/4 V1/5 V1/6 V2/1 V2/2 V2/3 V2/4 V2/5 V2/6 1 5 213038064 7135 3 1/4 13-10924 X X 10/08/2013 X 1443 1445 Scotts Bluff Scottsbluff X X Avenue I 26 Avenue I 1 01 78 1 1 1 1 1 2 02 2 01 1 10/12/2013 21DH52 NE 2013 PA 4T1BF28B44U371505 2004 Toyota UVS 4 door Sedan tan ELNORA H HUBER 308-632-8450 1406 AVENUE I, SCOTTSBLUFF, NE 69361 STATE FARM 179 8097-E19-27H 3 4500 1 SONNY'S LOT SONNY'S TOWING 18 18 2 30 G21023829 NE 308-632-8450 ELNORA HUBER 1406 AVENUE I, SCOTTSBLUFF, NE 69361 05/26/1924 X 1 03 X A2356953 215296 NE 2013 TE 1GCEK14T7YE145514 2000 Chevrolet SK1 black TONI BUETTNER 290832 STONEGATE ROAD, MINATARE, NE 69356 FARM BUREAU INSURANCE 0000000007752697 2 3500 4 18 18 2 45 H13470425 NE 308-225-0058 SHANIA SCHMALTZ 290832 STONEGATE ROAD, MINATARE, NE 69356 10/11/1995 X 1 01 X X
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Transcript of State of Nebraska Investigator’s Motor Vehicle Accident Report€¦ · Seat Eject Body Injury...
YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE
TOTALED $
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
ONE-WAY YES NOSTREET?
LONGITUDE
LATITUDE
OF NEAREST STREET, BRIDGE, RAILROAD CROSSINGFEET MILES
IF NOT AT INTERSECTIONN S E W
N S E W
IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN
NAME OF INTERSECTING ROADWAY
IF AT INTERSECTION
PRIVATE YES NOPROPERTY?
Total Numberof VehiclesDATE
OFACCIDENT
PLACEOF
ACCIDENT
ROAD ON WHICHACCIDENT OCCURRED
R. WORKZONECODES
S. PEDESTRIANCLASSIFICATIONCODES
DOES ACCIDENT INVOLVE DAMAGE TOSTATE DEPT. OF ROADS’ PROPERTY?
YES NO
DISTANCE FROMMILEPOST
COUNTY
CITY
STREET/HIGHWAY NO.
FEET
MILES ANDMILES
OF NEARESTCITY OR TOWN
OFMILEPOST
HIGHWAY NO.
STATE USE ONLY
INVESTIGATION MADE AT SCENE?HIT & RUN?Local No./District
AgencyCaseNo.
M M / D D / Y Y Y YS M T W TH F S
N S E W
R1 R2 R3 R4
N S E W
TIME OFACCIDENT
POLICENOTIFIED
State of Nebraska
Investigator’s Motor Vehicle Accident Report
S1 S2 S3 S4 S5-a S5-b S6-a S6-b
(In Military Time)
YES NOYES NO
Sheet _____ of _____
DR Form 40, Jan 09 THIS FORM REPLACES DR FORM 40, JAN 02PREVIOUS EDITIONS WILL BE DESTROYED.
A/1
A/2
B
C
D
V1/M
V2/M
E
F
V1/N
V2/N
G
H
V1/O
V2/O
I
V1/P
V2/P
J
V1/Q
V2/Q
K
CITATION YESPENDING NO
STATE(Of License)
DATE OFBIRTH
(MM / DD / YYYY)
LICENSEPLATE
VEHICLE NO. 1
YEAR(Plate Expires)
DRIVERLICENSE NO.
DRIVER
DRIVER ADDRESS CITY, STATE, ZIP
OWNER
PHONE
–
PHONE
–
LOCAL NO.
LOCAL NO.
CITATION NO.OWNER ADDRESS CITY, STATE, ZIP
VEHICLE IDNO. (VIN)
TOWED TO TOWED BY
VEHICLE
NO.STATE
(Of Plate)
SEXFEMALEMALE
INSURANCE COMPANY
POLICY NO.
/ /
CITATION YESPENDING NO
STATE(Of License)
DATE OFBIRTH
(MM / DD / YYYY)
LICENSEPLATE
VEHICLE NO. 2
YEAR(Plate Expires)
DRIVERLICENSE NO.
DRIVER
DRIVER ADDRESS CITY, STATE, ZIP
OWNER
PHONE
–
PHONE
–
LOCAL NO.
LOCAL NO.
CITATION NO.OWNER ADDRESS CITY, STATE, ZIP
VEHICLE IDNO. (VIN)
TOWED TO TOWED BY
VEHICLE
NO.STATE
(Of Plate)
SEXFEMALEMALE
YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE
TOTALED $INSURANCE COMPANY
POLICY NO.
/ /
1 2 3 4 5SEXSeat Eject Body Injury Trans. M FPosition Region Sev.
Complete this section for all injured persons(Complete a continuation report, if more than three were injured)
VEH. #
VEH. #
VEH. #
DATE OF BIRTH(MM / DD / YYYY)
L
V1/1
V1/2
V1/3
V1/4
V1/5
V1/6
V2/1
V2/2
V2/3
V2/4
V2/5
V2/6
1 52130380647135
3 1/4 13-10924 X
X
10/08/2013 X 1443
1445Scotts Bluff
Scottsbluff X
XAvenue I
26
Avenue I
1
01
78
1
1
1
1
1
2
02
2
01
1
10/12/2013
21DH52 NE2013PA
4T1BF28B44U3715052004 Toyota UVS 4 door Sedan tan
ELNORA H HUBER 308-632-8450
1406 AVENUE I, SCOTTSBLUFF, NE 69361
STATE FARM
179 8097-E19-27H
34500
1
SONNY'S LOT SONNY'S TOWING
18
18
2
30
G21023829 NE
308-632-8450ELNORA HUBER
1406 AVENUE I, SCOTTSBLUFF, NE 69361 05/26/1924
X
1
03
XA2356953
215296 NE2013TE
1GCEK14T7YE145514
2000 Chevrolet SK1 black
TONI BUETTNER
290832 STONEGATE ROAD, MINATARE, NE 69356
FARM BUREAU INSURANCE
0000000007752697
2
35004
18
18
2
45
H13470425 NE
308-225-0058SHANIA SCHMALTZ
290832 STONEGATE ROAD, MINATARE, NE 69356 10/11/1995
X
1
01
X
X
dor10137
Line
THE FOLLOWING INFORMATION IS REQUIRED FOR ALL ACCIDENTSINDICATE BY DIAGRAM WHAT HAPPENED
VEH N S E W ROAD ORNO. HIGHWAY NAME
1
2
1
202 03 04
01 05
08 07 06
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Driver DriverNo. 1 No. 2
ALCOHOLTESTING
OBJECT DAMAGED OWNER NAME ADDRESS PHONE APPROX. COST OF DAMAGE
$OBJECT DAMAGED OWNER NAME ADDRESS PHONE APPROX. COST OF DAMAGE
$NAME ADDRESS PHONE
–NAME ADDRESS PHONE
–
IndicateNorth
by Arrow
DESCRIPTION OF ACCIDENT BASED ON OFFICER’S INVESTIGATION
PR
OP
ER
TY
WIT
NE
SS
ES
AGENCY CASE NO.
YESNO
VEHICLE MOVEMENTBEFORE COLLISION
POINT OF IMPACT ANDMOST DAMAGED AREA
(Enter numbers for each vehicle)
AIRBAG DEPLOYED
01 Essentiallystraight ahead
02 Backing03 Changing lanes04 Overtaking/
Passing05 Turning right
06 Turning left07 Making U-turn08 Entering
traffic lane09 Leaving
traffic lane10 Parked11 Slowing or
stopped in traffic12 Other13 Unknown
00 None
09 Top & windows
10 Undercarriage
11 Total (all areas)
12 Other
1 Deployed - front2 Deployed - side3 Deployed - both front/side4 Not deployed5 Not applicable/
No airbag available6 Unknown
POINT OFIMPACT
MOSTDAMAGED
AREA
VEHICLE 1
POINT OFIMPACT
MOSTDAMAGED
AREA
VEHICLE 2
RESTRAINT USE
1 None used - vehicle occupant2 Lap & shoulder belt used3 Shoulder belt only used4 Lap belt only used5 Child safety seat used6 Child booster seat used7 DOT approved helmet used8 Costume helmet used9 Restraint use unknown
1 Neither alcohol nor drugs suspected2 Yes - alcohol suspected3 Yes - drugs suspected4 Yes - alcohol & drugs suspected5 Unknown
VEHICLE 1VEHICLE 1
VEHICLE 2VEHICLE 2
TOTALOCCUPANTS
ALCOHOLLEVEL
TESTED
BAC LEVEL
Driver Driver Pedes-No. 1 No. 2 trian
VEH VEH1 2
ALCOHOL/DRUGS
SUSPECTED
Y Y Y
N N N
OFFICER NO. TROOP/ DEPARTMENTTEAM/BEAT
INVESTIGATOR NAME (Print or Type) INVESTIGATOR SIGNATURE
Photographstaken?
DATE OFREPORT / /20_ _
13-10924
Ian McPherson
135 Scottsbluff Police Department
Approved by Ptl Lee Pinet #132 10/12/2013
01
X AVENUE I
01
01
X
1
1
01
X HIGHWAY 26 03
03
X
1
1
4 2
4 2
X
ON 10/08/13 AT APPROXIMATELY 1445HRS I RESPONDED TO THE INTERSECTION OF AVENUE I AND HIGHWAY 26 IN REFERENCE TO A MOTORVEHICLE COLLISION INVOLVING THREE VEHICLES. I SPOKE WITH DRIVER 1 WHO STATED THAT SHE WAS IN THE CENTER LANE OF AVENUE IAND HEADING SOUTH BOUND. DRIVER 1 STATED THAT SHE HAD A GREEN LIGHT AND WHEN SHE WENT THROUGH THE INTERSECTION SHEWAS HIT BY DRIVER TWO.I SPOKE WITH DRIVER TWO WHO STATED THAT SHE HAD BEEN STOPPED ON HIGHWAY 26 BY THE RED LIGHT.DRIVER TWO STATED THAT SHE WAS IN THE OUTSIDE LANE AND HEADING WEST BOUND. DRIVER TWO STATED THAT WHEN SHE GOT INTOTHE INTERSECTION SHE WAS HIT BY DRIVER ONE, WHICH PUSHED HER VEHICLE INTO DRIVER'S THREE VEHICLE. DRIVER TWO STATEDTHAT SHE HAD A GREEN LIGHT. I SPOKE WITH DRIVER THREE WHO STATED THAT HE HAD ALSO BEEN STOPPED FOR THE RED LIGHT ONHIGHWAY 26 BUT HE WAS IN THE INSIDE LANE ALSO HEADED WESTBOUND. DRIVER THREE STATED THAT HE DIDN'T SEE DRIVER ONEACTUALLY HIT DRIVER TWO ...
City Of Scottsbluff 2525 Circle Drive, Scottsbluff, NE 69361 308-630-6256 250Road Sign for HWY 26
DOR10040
Cross-Out
YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE
TOTALED $
Y Y
N NPOINT OFIMPACT
MOSTDAMAGED
AREA
POINT OFIMPACT
MOSTDAMAGED
AREA
CITATION YESPENDING NO
COUNTY
CITY
STATE(Of License)
1 2 3 4 5SEXSeat Eject Body Injury Trans. M FPosition Region Sev.
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
NAME ADDRESS
/ /LOCAL NO. MEDICAL FACILITY NAME EMS SERVICE NAME EMS RUN REPORT NO.
DATE OF ACCIDENT (MM / DD / YYYY)
ROAD ON WHICH ACCIDENT OCCURRED STREET/HIGHWAY NO.
PLACEOF
ACCIDENT
STATE USE ONLYLocal No./District
AgencyCaseNo.
State of Nebraska
Investigator’s Motor Vehicle Accident Continuation Report
DATE OFBIRTH
(MM / DD / YYYY)
Sheet _____ of _____
Complete this section for all injured persons
VEH. #
VEH. #
VEH. #
DATE OF BIRTH(MM / DD / YYYY)
DR Form 40a, Jan 09 THIS FORM REPLACES DR FORM 40a, JAN 02PREVIOUS EDITIONS WILL BE DESTROYED.
VEH. #
M
N
O
P
Q
LICENSEPLATE
VEHICLE NO.
YEAR(Plate Expires)
DRIVERLICENSE NO.
DRIVER
DRIVER ADDRESS CITY, STATE, ZIP
OWNER
PHONE
–
PHONE
–
LOCAL NO.
LOCAL NO.
CITATION NO.OWNER ADDRESS CITY, STATE, ZIP
VEHICLE IDNO. (VIN)
TOWED TO TOWED BY
VEHICLE
NO.STATE
(Of Plate)
SEXFEMALE
MALE
YEAR MAKE MODEL BODY STYLE COLOR ESTIMATED DAMAGE
TOTALED $INSURANCE COMPANY
POLICY NO.
/ /
02 03 04
01 05
08 07 06
Driver No. Driver No.___ ___
ALCOHOLTESTING
VEH N S E W ROAD ORNO. HIGHWAY NAME
VEHICLE MOVEMENTBEFORE COLLISION
POINT OF IMPACT ANDMOST DAMAGED AREA
(Enter numbers for each vehicle)
AIRBAG DEPLOYED
01 Essentiallystraight ahead
02 Backing03 Changing lanes04 Overtaking/
Passing05 Turning right
06 Turning left07 Making U-turn08 Entering
traffic lane09 Leaving
traffic lane10 Parked11 Slowing or
stopped in traffic12 Other13 Unknown
00 None
09 Top & windows
10 Undercarriage
11 Total (all areas)
12 Other
1 Deployed - front2 Deployed - side3 Deployed - both front/side4 Not deployed5 Not applicable/
No airbag available6 Unknown
VEHICLE ___ VEHICLE ___
VEHICLE ___VEHICLE ___
VEHICLE ___VEHICLE ___
RESTRAINT USE
1 None used - vehicle occupant2 Lap & shoulder belt used3 Shoulder belt only used4 Lap belt only used5 Child safety seat used6 Child booster seat used7 DOT approved helmet used8 Costume helmet used9 Restraint use unknown
1 Neither alcohol nor drugs suspected2 Yes - alcohol suspected3 Yes - drugs suspected4 Yes - alcohol & drugs suspected5 Unknown
TOTALOCCUPANTS
ALCOHOLLEVEL
TESTED
BAC LEVEL
Driver No. Driver No.___ ___
VEH VEH
___ ___
ALCOHOL/DRUGS
SUSPECTED
VEH. #
1.
2.
3.
4.
5.
6.
VEH. #
M
N
O
P
Q
VehicleCodesfrom
Overlay#2
Sequenceof Events
CITATION YESPENDING NO
STATE(Of License)
DATE OFBIRTH
(MM / DD / YYYY)
LICENSEPLATE
VEHICLE NO.
YEAR(Plate Expires)
DRIVERLICENSE NO.
DRIVER
DRIVER ADDRESS CITY, STATE, ZIP
OWNER
PHONE
–
PHONE
–
LOCAL NO.
LOCAL NO.
CITATION NO.OWNER ADDRESS CITY, STATE, ZIP
VEHICLE IDNO. (VIN)
TOWED TO TOWED BY
VEHICLE
NO.STATE
(Of Plate)
SEXFEMALE
MALE
INSURANCE COMPANY
POLICY NO.
/ /
VEH. #
1.
2.
3.
4.
5.
6.
3 4
43
4
3
4
3
43
4
3
53
3
3
4
4
33
44
2130380647135
1/4 13-10924
10/08/2013Scotts Bluff
ScottsbluffAvenue I
1310188 WY2013PA
1FTNW21P94EA46575
2004 Ford F250 Pickup truck silver / chrome
ROBERT BUSH 308-631-3377
1420 6TH AVENUE, MITCHELL, NE 69357
STATE FARM
0930750-A26-27
2
35004
18
18
2
45
01
X HIGHWAY 26
03
03
G65003942 NE
308-631-3377ROBERT BUSH
1420 6TH AVENUE, MITCHELL, NE 69356 10/09/1966
X
X
1
1
01
X
1
4 2
OFFICER NO. TROOP/ DEPARTMENTTEAM/BEAT
INVESTIGATOR NAME (Print or Type) INVESTIGATOR SIGNATURE
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ADDITIONAL - DIAGRAM & INFORMATION AS REQUIRED FOR ACCIDENT
IndicateNorth
by Arrow
AGENCY CASE NO.
DATE OFREPORT / /20_ _
OBJECT DAMAGED OWNER NAME ADDRESS PHONE APPROX. COST OF DAMAGE
– $OBJECT DAMAGED OWNER NAME ADDRESS PHONE APPROX. COST OF DAMAGE
– $NAME ADDRESS PHONE
–NAME ADDRESS PHONE
–
PR
OP
ER
TY
WIT
NE
SS
ES
13-10924
Ian McPherson
135 Scottsbluff Police Department
Approved by Ptl Lee Pinet #132 10/12/2013
OFFICER NO. TROOP/ DEPARTMENTTEAM/BEAT
INVESTIGATOR NAME (Print or Type) INVESTIGATOR SIGNATURE
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DATE OF ACCIDENT (MM / DD / YYYY)
ROAD ON WHICH ACCIDENT OCCURRED STREET/HIGHWAY NO.
PLACEOF
ACCIDENT
STATE USE ONLYLocal No./District
AgencyCaseNo.
State of Nebraska
Investigator’s Motor Vehicle Accident Description Continuation Report Sheet _____ of _____
DR Form 40b, Sep 12
5 52130380647135
Ian McPherson
135 Scottsbluff Police Department
1/4 13-10924
10/08/2013Scotts Bluff
ScottsbluffAvenue I
Approved by Ptl Lee Pinet #132 10/12/2013
BUT HE HAD BEEN HIT BY DRIVER'S TWO VEHICLE. DRIVER THREE STATED THAT IT WAS LIKE DRIVER TWO LOSTHER FRONT END. DRIVER THREE STATED THAT HE WAS PUSHED ONTO THE CURBED MEDIAN, AND TOOK OUTTHE SIGN THAT WAS IN THE MEDIAN.
DOR10040
Typewritten Text
COUNTY
DOR10040
Typewritten Text
CITY
DOR10040
Typewritten Text
DATE OF ACCIDENT
DOR10040
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DOR10040
Typewritten Text
DOR10040
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DOR10040
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