DMV USE ONLY AVT NUMBER DEPARTMENT OF MOTOR VEHICLES A Public Service Agency REPORT OF TRAFFIC COLLISION INVOLVING AN AUTONOMOUS VEHICLE 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 orcomplained 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 AVT NUMBER MANUFACTURER'S NAME Waymo LLC TELEPHONE NUMBER BUSINESS NAME Waymo LLC STREET ADDRESS STATE CITY ZIP CODE SECTION 2-ACCIDENT INFORMATION/VEHICLE 1 DATE OF ACCIDENT TIME OF ACCIDENT 10/19/2018 7:16 LICENSE PLATE NUMBER X MAKE VEHICLE YEAR AM □ PMl 2017 MODEL Pacifica Chrysler STATE VEHICLE IS REGISTERED IN VEHICLE IDENTIFICATION NUMBER CA ADDRESS/LOCATION OF ACCIDENT E l Camino Real at Calderon Ave, X D Vehicle was: COUNTY CITY M ountain View Moving Stopped in Traffic Involved in the Accident: D D Pedestrian Bicyclist Santa Clara D DRIVER LICENSE NUMBER INSURANCE COMPANY NAME OR SURETY COMPANYATTIME OF ACCIDENT POLICY NUMBER CA 9404 1 2 Other STATE POLICY PERI OD COMPANY NAIC NUMBER FRO M Describe Vehicle Damage UNK O 0 MOD OL316 {REV. 2/2017) WWW ZIP CODE NUMBER OF VEHICLES INVOLVED DRIVER'S FULL NAME {FIRST, MIDDLE, LAST) 0 STATE NONE X MINOR O MAJOR TO Shade in Damaged Area DATE OF BIRTH 2007 Honda Rebel LICENSE PLATE NUMBER VEHICLE IDENTIFICATION NUMBER STATE VEHICLE IS REGISTERED IN UNK Vehicle was: X D CA Moving Stopped in Traffic Involved in the Accident: DRIVER'S FULL NAME (FIRST, MIDDLE, LAST) D D Pedestrian Bicyclist NUMBER OF VEHICLES INVOLVED D other 2 DRIVER LICENSE NUMBER STATE DATE OF BIRTH CA INSURANCE COMPANY NAME OR SURETY COMPANY AT TIME OF ACCIDENT POLICY NUMBER COMPANY NAIC NUMBER POLICY PERIOD UNK FROM UNK D TO UNK Additional information attached. NAME (FIRST, MIDDLE, LAST) ADDRESS CITY CHECK ALL THAT APPLY X Injured D Deceased STATE X Driver D Passenger D ZIP CODE Bicyclist D Property 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 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 CITY STATE ) ZIP CODE D Additional information attached. □ Autonomous Mode X Conventional Mode A Waymo Autonomous Vehicle ("Waymo AV") was traveling at approximately 21 MPH westbound in Lane 2 of El Camino Real in Mountain View in self-driving mode. A passenger vehicle in Lane 1,to the left of the Waymo AV, began to change lanes into Lane 2 to avoid a box truck blocking two lanes of traffic, Waymo's test driver took manual control of the AV out of an abundance of caution, disengaged from self-driving mode, and began changing lanes into Lane 3. A motorcycle, traveling at approximately 28 MPH behind the Waymo AV, had just entered Lane 3 to overtake the Waymo AV on its right. The Waymo AV and motorcycle collided at the Way mo AV's right rear corner. The motorcyclist reported injuries and was transported to the hospital for treatment. The Waymo AV sustained minor damage to the rear bumper. D Additional information attached. OL 316 (REV, 212017) WWW ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(*) SHOULD BE EXPLAINED IN THE NARRATIVE WEATHER VEH VEH (MARK 1 to 2 ITEMS) 1 2 ✓ ✓ A. CLEAR B. CLOUDY MOVEMENT PRECEDING COLLISION VEH VEH OTHER ASSOCIATED FACTOR(s) 1 2 (MARK ALL APPLICABLE) A. STOPPED A. B. PROCEEDING STRAIGHT cvc SECTIONS VIOLATED CITED ✓ 0 X YES □ □ C. RAINING C. RAN OFF ROAD D. SNOWING D. MAKING RIGHT TURN E. FOG/VISIBILITY E. MAKING LEFT TURN F. OTHER F. MAKING U TURN B. VISION OBSCUREMENT G. WIND G. BACKING C. INATTENTION* H. SLOWING/STOPPING D. STOP & GO TRAFFIC E. ENTERING/ LEAVING RAMP LIGHT ING A. DAYLIGHT ✓ ✓ I. PASSING OTHER VEHICLE B. DUSK- DAWN J. CHANGING LANES ✓ □ F. PREVIOUS COLLISION C. DARK -STREET LIGHTS K. PARKING MANUEVER G. UNFAMILIAR WITH ROAD D. DARK - NO STREET LIGHTS L. ENTERING TRAFFIC H. DEFECTIVE WEH EQUIP E. DARK-STREET LIGHTS NOT FUNCTIONING* M . OTHER UNSAFE TURNING ROADWAY SURFACE ✓ ✓ 0 . PARKED I. UNINVOLVE D VEHICLE B.WET P. MERGING J. OTHER* C. SNOWY - ICY Q. TRAVELING WRONG WAY K. NONE APPARENT R. OTHER* L. RUNAWAY VEHICLE D. SLIPPERY (MUDDY, OILY, ETC.) ROADWAY CONDITIONS A. HOLES, DEEP RUT' NO □ □ □ □ A. HEAD-ON B. LOOSE MATERIAL ON ROADWAY C. OBSTRUCTION ON ROADWAY* D. CO NSTRU CTION REPAIR ZONE B. SIDE SWIPE .✓ C. REAR END D. BROADSIDE E. REDUCED ROADWAY WIDTH E. HIT OBJECT F. FLOODED* F. OVERTURNED G. OTHER* G. VEHICLE/PEDESTRIAN SECTION 6 - YES TYPE OF COLLIS ION ( MARK 1 TO 2 ITEMS) H. NO UNUSUAL CONDITIONS □ □ □ CITED 0 □ N. XING INTO OPPOSING LANE A. DRY NO ✓ ✓ H. OTHER* 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 DIREGTORIAVTHORIZED REPRESENTATIVE PRINTED NAME AND T ITLE TELEPHONE NUMBER Matthew Salwasser, Program Manager SIGNATURE DATE SIGNED X 11/1/2018 OL 316(REV. 2/2017) WWW