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TRACS KEY NO. <br />Investigator’s Motor Vehicle Crash Report - Vehicle <br />Sheetof <br />36 <br />L <br />MOTOR VEHICLE UNIT TYPEDRIVER PRESENT? <br />101 <br />VEHICLE NO. <br />YESNO <br />01 - Motor Vehicle in Transport 02 - Parked Motor Vehicle 03 - Working Vehicle/Equipment <br />VEHICLE OWNER NAME (Last, First, Middle) <br />CONTACT PHONE <br />JONES, CHANDRA, S <br />MAILING ADDRESSCITYSTATEZIP <br />203 E PINE STREETALDANE68810 <br />LICENSE PLATE NO.STATEREG. YEARMAKEMODELMODEL YEARCOLOR <br />8E1072NE2021CHRYSLER2002012RED <br />LICENSE PLATE TYPE <br />VIN <br />PASSENGER <br />1C3CCBCG7CN158646 <br />INSURANCE COVERAGE <br />INSURANCE COMPANYINSURANCE POLICY NO. <br />SHELTER MUTUAL INSURANCE210260103389500002 <br />01 - Yes 02 - No 99 - Unk. <br />MOTOR VEHICLE TYPE CATEGORYSPECIAL FUNCTION OF MOTOR VEHICLE IN TRANSPORTEMERGENCY MOTOR VEHICLE USE <br />10 <br />00 - No Special Function01 - Emergency Operation, Emergency <br />Body Type <br />01 - Ambulance Warning Equipment in Use <br />01 - All-Terrain Vehicle / Cycle (ATV/ATC) <br />02 - Bus – Charter/Tour02 - Emergency Operation, Emergency <br />02 - Golf Cart <br />97 <br />03 - Bus – Childcare/Daycare Warning Equipment Not in Use <br />03 - Low Speed Vehicle <br />00 <br />04 - Bus – Intercity03 - Non-Emergency, Non-Transport <br />04 - Recreational Off-Highway Vehicles (ROV) <br />05 - Bus – School (Public or Private)04 - Non-Emergency, Transport <br />05 - Snowmobile <br />06 - Bus – Shuttle97 - Not Applicable <br />06 - Moped or motorized bicycle <br />07 - Bus – Transit/Commuter99 - Unknown <br />07 - Motorcycle - 2 Wheel <br />08 - Bus – Other <br />08 - Motorcycle - 3 Wheel <br />09 - Farm Vehicle <br />09 - Autocycle <br />MOTOR VEHICLE <br />10 - Fire Truck <br />10 - Passenger Car <br />AUTOMATED DRIVING SYSTEM(S) <br />11 - Highway/Maintenance <br />11 - Passenger Van (less than 9 seats) <br />Automation System(s) in Vehicle? <br />02 <br />12 - Mail Carrier <br />12 - (Sport) Utility Vehicle <br />01 - Yes <br />13 - Military <br />13 - Pickup (10,000 lbs or less) <br />02 - No <br />14 - Non-Transport Emergency Services Vehicle <br />14 - Pickup (greater than 10,000 lbs)** <br />99 - Unknown <br />15 - Other Incident Response <br />15 - Medium/Heavy Truck (greater than 10,000 lbs GVWR)** <br />16 - Police <br />16 - Single-Unit Truck** <br />Automation System Levels in Vehicle 00 <br />17 - Public Utility <br />17 - Truck Tractor** <br />(up to 5 choices) <br />18 - Rental Truck (Over 10,000 lbs) <br />18 - Other Trucks <br />00 - No Automation <br />19 - Safety Service Patrols – Incident Response <br />19 - 9 or 12-Passenger Van** <br />01 - Driver Assistance <br />20 - Taxi <br />20 - 15-Passenger Van** <br />02 - Partial Automation <br />21 - Towing – Incident Response <br />21 - Cargo Van (10,000 lbs or less) <br />03 - Conditional Automation <br />22 - Truck Acting as Crash Attenuator <br />22 - Cargo Van (greater than 10,000 lbs GVWR)** <br />04 - High Automation <br />23 - Vehicle Used for Electronic Ride-hailing (Uber, Lyft, etc.) <br />23 - Large Limo** <br />05 - Full Automation <br />98 - Other <br />24 - Mini-bus** <br />06 - Automation Level Unknown <br />99 - Unknown <br />25 - School Bus** <br />99 - Unknown <br />26 - Transit Bus** <br />HIT AND RUN? <br />27 - Other Bus Type** <br />02 <br />01 - Yes - Driver or Car/Driver Left Scene <br />Automation System Levels <br />28 - Motor Home (10,000 lbs or less GVWR) <br />00 <br />02 - No - Did Not Leave Scene <br />Engaged at Time of Crash <br />29 - Motor Home (greater than 10,000 lbs GVWR)** <br />99 - Unknown <br />(up to 5 choices) <br />30 - Motorcoach** <br />31 - Construction Equipment (backhoe, bulldozer, etc.)00 - No Automation <br />VEHICLE MANEUVER / ACTION <br />32 - Farm Equipment (tractor, combine harvester, etc.)01 - Driver Assistance <br />01 <br />01 - Movement Essentially Straight Ahead <br />98 - Other02 - Partial Automation <br />02 - Backing <br />99 - Unknown03 - Conditional Automation <br />03 - Changing Lanes <br />04 - High Automation <br />Did this motor vehicle display a <br />10 - Slowing <br />04 - Entering Traffic Lane <br />05 - Full Automation <br />hazardous materials (HM) placard? <br />11 - Stopped in Traffic <br />05 - Leaving Traffic Lane <br />06 - Automation Level Unknown <br />01 - Yes** 97 - Not Applicable <br />12 - Turning Left <br />06 - Making a U-Turn <br />99 - Unknown <br />02 - No 99 - Unknown <br />13 - Turning Right <br />07 - Negotiating a Curve <br />**Heavy Truck/Bus form must be completed <br />08 - Parked98 - Other <br />99 - Unknown <br />09 - Passing/Overtaking a Vehicle <br />Number of trailing unitsVEHICLE CONTRIBUTING CIRCUMSTANCE(S) <br />97 <br />97 - Not Applicable (vehicle with no trailing units)00 - None <br />01 - Body, Doors <br />00 <br />02 - Brakes <br />Vehicle crash damages <br />INITIAL CONTACT POINTDAMAGED AREA(S) <br />(check up to 4) <br />03 - Exhaust System <br />equal to or less than <br />04 - Lights (head, signal, tail) <br />$1,000 are classified <br />05 - Mirrors <br />as non-reportable. <br />06 - Power Train <br />DAMAGE ESTIMATE <br />07 - Steering <br />08 - Suspension <br />Totaled <br />09 - Tires <br />10 - Truck Coupling/Trailer Hitch/Safety Chains <br />$ 3000 <br />11 - Wheels <br />12 - Windows/Windshield <br />13 - Wipers <br />EXTENT OF DAMAGE <br />98 - Other <br />00 - No Damage <br />99 - Unknown <br />01 - Minor Damage <br />00 - Non-Collision <br />12 <br />02 - Functional Damage <br />13 - Top <br />03 - Disabling Damage <br />TOWED DUE TO DISABLING DAMAGE <br />14 - Undercarriage <br />04 - Vehicle Not at Scene <br />01 - Not Towed <br />00 - No Damage15 - All Areas 02 <br />15 - Cargo Loss <br />02 - Towed Due to Disabling Damage <br />03 <br />16 - Vehicle Not at Scene <br />13 - Top16 - Vehicle Not at Scene <br />03 - Towed Not Due to Disabling Damage <br />99 - Unknown <br />14 - Undercarriage99 - Unknown <br />L21031656 <br />Agency Case No. <br /> <br />