STATE OF CALIFORNIA

dmv use only
AVT NuMBER

DEPARTMENT OF MOTOR VEHICLES

RepoRt of tRaffic accident involving
an autonomous vehicle

®

a Public service agency

NAME

Instructions: Please print within the spaces and boxes on this form. If you need to provide additional information on a
separate piece of paper(s) or you include a copy of any law enforcement agency report, please check the box to indicate
“Additional Information Attached.”
•  Write unk (for unknown) or none in any space or box when you do not have the information on the other party involved.
•  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 self-insurance.
•  Place the National Association of Insurance Commissioners (NAIC) number for your Insurance or Surety Company in the
boxes provided. The NAIC number should be located on the proof of insurance provided by you company or you can contact
your insurer for that information.
•  Identify any person involved in the accident (driver, passenger, bicyclist, pedestrian, etc) that you saw was injured or complained
of bodily injury or know to be deceased.
•  Record in the PROPERTY DAMAGE line any damage to telephone poles, fences, street signs, guard post, trees, livestock,
dogs, buildings, parked vehicles, etc., including a description of the damage.
•  Once you have completed this report, please mail to: Department of Motor Vehicles, Occupational Licensing Branch, P.O.
Box 932342, MS: L224, Sacramento, CA 94232-3420
section 1 — manufactuReR’s infoRmation
MANufACTuRER’S NAME

AVT NuMBER

BuSINESS NAME

TELEPhONE NuMBER

(
STREET ADDRESS

CITY

)

STATE

ZIP CODE

section 2 — accident infoRmation
DATE Of ACCIDENT

TIME Of ACCIDENT

VEhICLE YEAR

AM
LICENSE PLATE NuMBER

MODEL

VEhICLE IDENTIfICATION NuMBER

ADDRESS/LOCATION Of ACCIDENT

vehicle
was:

MAkE

PM
STATE VEhICLE IS REGISTERED IN

CITY

Moving
Stopped in Traffic

involved in
the accident:

COuNTY

Pedestrian
Bicyclist

DRIVER’S fuLL NAME (First, Middle, last)

DRIVER LICENSE NuMBER

INSuRANCE COMPANY NAME OR SuRETY COMPANY AT TIME Of ACCIDENT

POLICY NuMBER

COMPANY NAIC NuMBER

STATE

ZIP CODE

NuMBER Of VEhICLES INVOLVED

Other
STATE

DATE Of BIRTh

POLICY PERIOD

TO

fROM

section 3 — otheR paRty’s infoRmation
VEhICLE YEAR

MODEL

LICENSE PLATE NuMBER

VEhICLE IDENTIfICATION NuMBER

vehicle
was:

Moving
Stopped in Traffic

involved in
the accident:

STATE VEhICLE IS REGISTERED IN

Pedestrian
Bicyclist

DRIVER’S fuLL NAME (First, Middle, last)

DRIVER LICENSE NuMBER

INSuRANCE COMPANY NAME OR SuRETY COMPANY AT TIME Of ACCIDENT

POLICY NuMBER

COMPANY NAIC NuMBER

NuMBER Of VEhICLES INVOLVED

Other
STATE

DATE Of BIRTh

POLICY PERIOD

fROM

TO

additional information attached.
OL 316 (NEW 10/2013) WWW

*OL316*

 section 4 — injuRy/death, pRopeRty damage
NAME (First, Middle, last)

ADDRESS

check all that apply

CITY

Injured

Deceased

STATE

Driver

Passenger

ZIP CODE

Bicyclist

Property

NAME (First, Middle, last)

ADDRESS

check all that apply

CITY

Injured

Deceased

STATE

Driver

Passenger

ZIP CODE

Bicyclist

Property

PROPERTY DAMAGE

PROPERTY OWNER’S NAME

TELEPhONE NuMBER

(
STREET ADDRESS

CITY

)

STATE

WITNESS NAME

ZIP CODE

TELEPhONE NuMBER

(
STREET ADDRESS

CITY

)

STATE

WITNESS NAME

ZIP CODE

TELEPhONE NuMBER

(
STREET ADDRESS

CITY

)

STATE

ZIP CODE

additional information attached.
section 5 — accident details - descRiption
Autonomous Mode

Conventional Mode

additional information attached.
section 6 — ceRtification
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
I further certify that I am the authorized Administrator of the program for the above named employer.
PROGRAM DIRECTOR/AuThORIZED REPRESENTATIVE PRINTED NAME AND TITLE

TELEPhONE NuMBER

(
SIGNATuRE

)

DATE SIGNED

X
OL 316 (NEW 10/2013) WWW

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