Professional Documents
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SF 91
SF 91
ACCIDENT REPORT
INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X,
items 72 thru 82c are filled on by the operator's supervisor. Section XI thru XIII are filled out
by an accident investigator for bodily injury, fatality,and/or damage exceeding $500.
SECTION I - FEDERAL VEHICLE DATA
8. MAKE
9. MODEL
NO
SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed)
12. DRIVER'S NAME (Last, first, middle)
$
22. TAG NUMBER AND STATE
23b. POLICY NUMBER
23c. TELEPHONE NUMBER
24. VEHICLE IS
CO-OWNED
RENTAL
LEASED
PRIVATELY OWNED
SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed)
27. NAME (last, first, middle)
28. SEX
30. ADDRESS
DRIVER
PASSENGER
INJURED
HELPER
PEDESTRIAN
35. TRANSPORTED BY
FED
OTHER (2)
36. TRANSPORTED TO
38. SEX
40. ADDRESS
DRIVER
PASSENGER
INJURED
HELPER
PEDESTRIAN
45. TRANSPORTED BY
46. TRANSPORTED TO
47. Pedestrian
FED
TO
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (crossing intersection with signal, against signal, diagonally; in roadway playing,
walking, hitchhiking, etc.)
NSN 7540-00-634-4041
Previous edition not usable
STANDARD FORM 91
(2/2004)
Prescribed by GSA-FMR 102-34.295
SECTION IV - ACCIDENT TIME AND LOCATION (Use section VII if additional space is needed.)
49. PLACE OF ACCIDENT (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business,
residential, open country, etc.); Road description).
AM
PM
52. POINT OF IMPACT
(Check one for each
vehicle)
FED
AREA
a.
b.
c.
d.
e.
f.
g.
Front
R. Front
L. Front
Rear
R. Rear
L. Rear
R. Side
h. L. Side
53. DESCRIBE WHAT HAPPENED (Refer to vehicles as "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of vehicles, road conditions,
weather conditions, weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signal,etc.), condition of light (daylight, dusk, night,
dawn, artificial light, etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.)
SECTION V - WITNESS/PASSENGER (Witness must fill out SF 94, Statement of Witness) (Continue in Section VIII.)
71b. VIOLATION(S)
SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND
PAPER.
73. ORIGIN
74. DESTINATION
DATE
82. COMPLETED
BY DRIVER'S
SUPERVISOR
NO
DATE
IN WRITING (Explain)
YES
77. ACCIDENT
OCCURRED
YES (Explain)
81. DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHER
THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?
NO
YES (Explain)
b. COMENTS
NO
NO
NAME
a.
c.
b.
d.
NAME
DATE
86. ADDITIONAL COMMENTS (Indicate section and item number of each comment).
a. SIGNATURE
b. DATE
d. TITLE
d. TITLE
e. OFFICE
e. OFFICE
AREA CODE
EXTENSION
AREA CODE