AN AUTONOMOUS VEHICLE REPORT OF TRAFFIC ACCIDENT INVOLVING new use? ore-N AVT NUMBER NAME Instructions: print within the spaces and boxes on this form. if you need to provide additional information on a separate piece of paperl?e) or you include a copy of any law enforcement agency report, please check thebcx to indicate "Additional Attached.? 9 Write Link (for unknown) or none in any space or box when you do not have the information on the other party invcived. Give insurance. information that is complete and which correctly and fully Identifies the company that issued the insurance policy or surety bond, or whether there is a certificate of eelt~ineurenoe Piece the Nationei of Insurance Commissioners number for your Insurance or Surety Company in the boxs provided. The number ehouid be located on the proof of insurance provided by you company or you can contact your insurer for that information. - Identifyeny person tnvoived in the occident (drive-r, passenger, bicyotiet. pedestrian, etc) that you eew was iniored or complained of bodily lniury or know 'to- be deceased. Record in the PROPERTY DAM-AGE line any damage to telephone poles, fence-e, street signs, guard poet, tree's, livestock, clogs, buildings, perked vehicles, etc., including a deecriptlon oi the damage. Once you have completed this report, please mail to: Department of Motor Vehicles, Occupational Licensing Branch, RC. BOX 932342, MS: L224, Sacramento, CA 94232-3420 SECTION 1 MANU-FAGTUREERW NAME AVT NUMBER LoXus BUSINESS NAME TELEPHONE NUMBER 'Googlo Auto LLC . STREET "noon EBS STATE z'ie Coors SECTION 2 w- DATE OF ACCIDENT Tina on ACCIDENT YEAR MAKE MODEL 02,!14l2016 AM PM 2012 Lexus Hooded PLATE NUMBER NUMBER owe VEHECLE Is REGISTERED in or AGGIDENT CITY COUNTY 21? oboe E1 Crimino- Real and Casino St Mountain View Santa Clara CA. 94043 I NUMBER INVOLVED- wae: El Stopped in Traffic the Aeoident: Other . 1 oniven'e FULL NAME LAST) LICENSE NUMBER STATE 1 DATE or resonance NAME OR SURETY COMPANY in TIME oe'no'oioenr Pouor ncMeen cornered:r were nuneen Poucv eann moo, TO SECYION 3 w? OTHKFE INFORMATION YEAH MODEL I 2002 Ncw?yor Lowfloor Articulated Bus, series 2300 LICENSE PLATE NUMBER yer-iioLE NUMBER VEHICLE l8 RED iN Vehicle Moving involved in El Pedestrian was: ill Siopped in name the Accident: El Bioyotisi Other 1 DRIVE FULL NAME LAST) LICENSE NUMBER STATE OF BIRTH INSURANCE COMPANY NAME on sorrow company re TIME OF ACCIUENT eoucv wuneen COMPANY NMG NUMBER node? ne'nioo'" -.FROM TO Additional information attached. CL 318 101%13) SEQTIQN 4- ?m NAME MIBIJL 5. MS cm QTATE ZIP CODE (?n-max ALL THAT APPLY injured Deceaaed Driver Pass-anger Bicycfis?r El Property NAME mamas cm mam: ZIP CODE ALL. THAT [If ln}urad Decaasad CI [Driver Passenger [3 BicycIi-s-t F?mpariy DAMAGE I I I I owNEw-a MAME TELEPHONSHUMHEH ADDRESS cm Ema zmcooa NAME WW5 NUMBER . BTHEET mamas CITY ESTATE 21p CODE NAME TELEPHONE STREET momma . cm? STATE 2w cons Additimmi attmhed. 3 w- mamm -- Autonomoua Mode C3 Conventional Moda- A Gong-[e Lax usunoclcl vehicle: ("Gaogia was traveling in autonomous mode castbeuud an El Cumino Real in Mountain View in thes- fur lane approaching {ha Castro St. intersection. As the Gmgle 2W approached the intel?SEction. it sigrmled its intent to make a right turn. on red 1mm Castro St The Googie ATV then moved F0 tlhlil- rigiwhand side of the lane to pass- tm'l'?c in the sme- lune that mm 3'1.th interwctinn and" procaeding straight. Howwer. the (Boogie AV had to can.an to 21 310p and go around sandbags around a mum drain that were. blanking its path. When the Eight turned green, traffic in ?lm lane omtinued past the After a few cars had passed. the Gomgie AV begun proch hack. inm the center of the lane to pass the sand bags. A public transit bus was app-matching from behind. The Gmgle AV lust (trim? saw the bus approaching in the: 131?! side mirror but balievcd the bus wouic?l stop or sln?w aliow the: Google AV to continue. Apprmimately three. seconds Ian-31*. as the Goo-gla- AV was Immerng the Samar of the. 1mm it: made wmnut with the skin: oi" the bus. The: Gong-1e AV was {warming in autonomous mode and traveling at 1353 than 3 mph. and the: bus was tram-ng at about 134 the. time, of The, (73003.1(: AV sustuirm?d body damage the ie?. from Fendm: the left from wheal am} one of its driver?S-aida Bangers. There were no injuries l?tspol'teci at the scant}. . Additional i??fmmatian attache-d. 6 i certify (w declare) under pana?y afperjury wider the laws of the State of California ma? thee foregoing is true and correct i- Furth?r certify that I am the: au?mriz?d Mmmistmior at this? program for #30 Wave mde Wiping/m; pnonM baincmmumonizm hiy?sarm?nva PRINTED NAME mo TITLE Mars Oman . . .. SIGNATURE . DATE ED 2725/? I - ?aw?H- rm.?