DMV AVT NUMBER REPORT OF TRAFFICACCIDENT INVOLVING AN AUTONOMOUS VEHICLE DEPARTMENT OF MOTOR VEHICLES 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 MANUFACTURER'S NAME GM Cruise LLC TELEPHONE NUMBER BUSINESS NAME Cruise CITY STREET ADDRESS DATE OF ACCIDENT TIME OF ACCIDENT 01/02/2018 9: 27 LICENSE PLATE NUMBER VEHICLE IDENTIFICATION NUMBER Vehicle was: PM 2017 St. & 16th St Moving ed in Traffic D Sta CITY COUNTY STATE ZIP CODE San Francisco San Francisco CA 94103 Involved in the Accident: D D Pedestrian Bic clist NUMBER OF VEHICLES INVOLVED D DRIVER'S FULL NAME (FIRST, MIDDLE, LAST) DRIVER LICENSE NUMBER INSURANCE COMPANY NAME OR SURETY COMPANY AT TIMEOF ACCIDENT POLICY NUMBER COMPANY NAIC NUMBER POLICY PERIOD Vehicle was: D D STATE Moving Sta ed in Traffic Involved in the Accident: DATE OF BIRTH STATE VEHICLE IS REGISTERED IN D Pedestrian Bic clist NUMBER OF VEHICLES INVOLVED D Other DRIVER'S FULL NAME (FIRST, MIDDLE, LAST) DRIVER LICENSE NUMBER unk unk INSURANCE COMPANY NAME OR SURETY COMPANY AT TIME OF ACCIDENT POLICY NUMBER unk unk COMPANY NAIC NUMBER POLICY PERIOD unk FROM D 1 Other VEHICLE IDENTIFICATION NUMBER LICENSE PLATE NUMBER ZIP CODE VEHICLE YEAR AM ADDRESS/LOCATION OF ACCIDENT Valencia STATE STATE DATE OF BIRTH TO Additional information attached. OL 316 (NEW 10/2013) WWW IIIIIIIII IIIII Illlllll lllllllll llll NAME (FIRST, MIDDLE,LAST) GM Cruise LLC STATE CITY ADDRESS CHECK ALL THAT APPLY O Injured D Deceased D Driver D Passenger D ZIP CODE Bicyclist Property NAME (FIRST, MIDDLE, LAST) STATE CITY ADDRESS CHECK ALL THAT APPLY O Injured D Deceased D Driver D Passenger D Bicyclist ZIP CODE D Property PROPERTY DAMAGE Left rear tail light damage TELEPHONE NUMBER PROPERTY OWNER'S NAME GM Cruise LLC STREET ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE WITNESS NAME STREET ADDRESS WITNESS NAME CITY STREET ADDRESS D Additional information attached. Autonomous Mode D Conventional Mode This statement is amended from the original filed on 1/10/2018 to correct the phrase "sustained some damage to its right rear light" by replacing the phrase with "sustained some damage to its left rear light". A Cruise autonomous vehicle ("Cruise AV"), operating in autonomous mode, was involved in a collision while making a right hand turn from northbound Valencia Street onto 16th Street. The Cruise AV was stopped at a green light in between crosswalks of Valencia Street and 16th Street, waiting for pedestrians to cross over 16th Street. A different pedestrian from the southwest corner of Valencia and 16th ran across Valencia Street, against the "do not walk" symbol, shouting, and struck the left side of the Cruise AV's rear bumper and hatch with his entire body. There were no injuries but the Cruise AV sustained some damage to its left rear light. The 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 TELEPHONE NUMBER Kevin Chu, Associate Director, AV Engineering SIGNATURE X DATE SIGNED 1/25 /2018 OL 316 (NEW 10/2013) WWW