DMV USE ONLY AVT NUMBER Department of Motor Vehicles REPORT OF TRAFFIC ACCIDENT INVOLVING A Public Service Agency NAME AN AUTONOMOUS VEHICLE 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 MANUFACTURER'S NAME AVT NUMBER GM Cruise LLC BUSINESS NAME TELEPHONE NUMBER Cruise ( STREET ADDRESS CITY SECTION 2 - ACCIDENT INFORMATION DATE OF ACCIDENT TIME OF ACCIDENT 10:55 01/28/2018 LICENSE PLATE NUMBER VEHICLE STATE ZIP CODE STATE ZIP CODE CA 94103 VEHICLE YEAR 0 PM 2017 IDENTIFICATION NUMBER ADDRESS/LOCATION OF ACCIDENT CITY Duboce Ave & Mission St Vehicle O Moving was: 0 Sto ed in Traffic COUNTY San Francisco San Francisco Involved In O Pedestrian the Accident: 0 Bic cllst 0 Other 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 POLICY PERIOD NUMBER OF VEHICLES INVOLVED 2 STATE DATE OF BIRTH SECTION 3 - OTHER PARTY'S INFORMATION VEHICLE YEAR MODEL LICENSEPLATE NUMBER VEHICLE IDENTIFICATION NUMBER unk unk Vehicle was: STATE VEHICLEIS REGISTERED IN unk D Moving 0 Sta ed in Traffic unk Involved in the Accident: DRIVER'S FULL NAME (FIRST.MIDDLE, LAST) unk INSURANCE COMPANY NAME OR SURETY COMPANY AT TIMEOF ACCIDENT unk COMPANY NAIC NUMBER unk 0 Additional information attached. OL 316 (NEW 10/2013)-WWW O Pedestrian 0 Bic clist O Other NUMBER OF VEHICLES INVOLVED 2 DRIVER LICENSE NUMBER STATE unk POLICY NUMBER unk POLICY PERIOD FROM TO DATE OFBIRTH SECTION 4 - INJURY/DEATH, PROPERTY DAMAGE NAME (FIRST, MIDDLE, LAST) GM Cruise LLC ADDRESS CITY CHECK ALL THAT APPLY O Injured 0 Deceased STATE D Driver D Passenger D ZIP CODE 0 Property Bicyclist NAME (FIRST, MIDDLE, LAST) ADDRESS CITY CHECK ALL THAT APPLY O Injured D Deceased STATE D Driver D Passenger ZIP CODE D Bicyclist D Property PROPERTY DAMAGE Small scratch on passenger side front window PROPERTY OWNER'S NAME TELEPHONE NUMBER STREET ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE . WITNESS NAME STREET ADDRESS WITNESS NAME TELEPHONE NUMBER ) ( STREET ADDRESS D CITY STATE ZIP CODE Additional information attached. D Autonomous Mode 0 Conventional Mode A Cruise autonomous vehicle ("Cruise AV"), operating in manual mode, was stopped behind a taxi on Duboce Avenue just past Guerrero. The driver of the taxi exited his vehicle, approached the Cruise AV, and slapped the front passenger window, causing a scratch. There were no injuries and police were not called. D Additional information attached. 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 TELEPHONENUMBER Kevin Chu, Associate Director, AV Engineering SIGNATURE X DATE SIGNED 02/06/ 201 8