Alaska Motor Vehicle Crash Form 12-209

Crash Information

Total Number of Vehicles

Crash Date

Crash Time

Crash Time Unknown

Street or Highway Crash Occurred On

City or Borough Crash Occurred In

Name of Cross Street, Highway, Bridge, etc.

Distance From Cross Street

Unit

Direction From Cross Street

Weather If other weather, describe

Lighting If other lighting, describe

Roadway / Junction If other roadway, describe

Road Surface If other surface, describe

First Sequence of Events What was the first thing you crashed into, or what was the first event that resulted in the crash?)

If live animal, describe

Location of First Sequence of Events Where did the crash happen first?

Did police investigate this crash?

Your Driver Information

Your First Name

Your Middle Name

Your Last Name

Your Suffix

Your Date of Birth

Your Contact Telephone

Phone Number

Extension

Your Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Your Driver License Number

Your Driver License State

Your Driver License Country

Your Vehicle Information

Your Vehicle Damage

Number of Occupants

First Area of Impact Impact Diagram

Your Vehicle Owner's First Name

Your Vehicle Owner's Middle Name

Your Vehicle Owner's Last Name

Your Vehicle Owner's Suffix

Your Vehicle Owner's Telephone

Phone Number

Extension

Your Vehicle Owner's Email

Your Vehicle Owner's Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Your Vehicle Year

Your Vehicle Make

Your Vehicle Model

Your Vehicle License Plate Number

Your Vehicle License Plate State

Your Vehicle Identification Number

Your Vehicle's Direction of Travel

Damage Estimate over $501?

Your Vehicle Driver's Injury Status Enter vehicle passengers below

Roadway Circumstances (that may have contributed to the crash) If other roadway cirsumstance, describe

Your Vehicle Action If other action, describe

Traffic Control

Vehicle Configuration

Rental Car

Government Owned Vehicle

Company Owned Vehicle

Crash Description

Crash Description Write a brief narrative describing the crash

Other Driver's Information

Other Driver's First Name

Other Driver's Middle Name

Other Driver's Last Name

Other Driver's Suffix

Other Driver's Date of Birth

Other Driver's Telephone

Phone Number

Extension

Other Driver's Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Other Driver's License Number

Other Driver's License State

Other Driver's Country

Other Driver Vehicle Information

Other Vehicle Damage

Other Vehicle No. of Occupants

Other Vehicle First Area of Impact Impact Diagram

Other Vehicle Owner's First Name

Other Vehicle Owner's Middle Name

Other Vehicle Owner's Last Name

Other Vehicle Owner's Suffix

Other Vehicle Owner's Telephone

Phone Number

Extension

Other Vehicle Owner's Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Other Vehicle Year

Other Vehicle Make

Other Vehicle Model

Other Vehicle License Plate Number

Other Vehicle License Plate State

Other Vehicle's Direction of Travel

Damage Estimate over $501?

Other Vehicle Driver's Injury Status Enter vehicle passengers below

Other Driver's Roadway Circumstances (that may have contributed to the crash) If other roadway circumstance, describe

Other Driver's Vehicle Action If other action, describe

Other Driver's Traffic Control Traffic control for the other driver may have been different from yours

Other Driver's Vehicle Configuration

Rental Car

Governement Owned Vehicle

Company Owned Vehicle

Injury Section

Fill in the name of injured person, injury status, telephone number, and which vehicle they occupied when the crash occurred

Injured Person's First Name

Injured Person's Middle Name

Injured Person's Last Name

Injured Person's Suffix

Injury Status

Phone Number

Extension

License Plate Number Of Vehicle Injured Person Was In

Injured Person's First Name

Injured Person's Middle Name

Injured Person's Last Name

Injured Person's Suffix

Injury Status

Phone Number

Extension

License Plate Number Of Vehicle Injured Person Was In

Injured Person's First Name

Injured Person's Middle Name

Injured Person's Last Name

Injured Person's Suffix

Injury Status

Phone Number

Extension

License Plate Number Of Vehicle Injured Person Was In

Injured Person's First Name

Injured Person's Middle Name

Injured Person's Last Name

Injured Person's Suffix

Injury Status

Phone Number

Extension

License Plate Number Of Vehicle Injured Person Was In

Certificate of Insurance

Failure to complete the Certificate of Insurance could result in the suspension of your driver's license

Crash Information

Crash Date

Crash Location

Driver Information

Driver Last Name

Driver First Name

Driver Middle Name

Driver Suffix

Driver Birth Date

Driver Phone

Phone Number

Extension

Driver Email

Driver Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Driver License Number

Driver License State

Vehicle Owner Information

Vehicle Owner Last Name

Vehicle Owner First Name

Vehicle Owner Middle Name

Vehicle Owner Suffix

Vehicle Owner Birth Date

Vehicle Owner Phone

Phone Number

Extension

Vehicle Owner Mailing Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Vehicle Owner License Number

Vehicle Owner License State

Vehicle Information

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle License Plate Number

Vehicle License Plate State

Vehicle Identification Number

Rental Car

Governement Owned Vehicle

Company Owned Vehicle

Insurance Information

Did you have a current automobile liability policy in effect covering this accident?

Insurance Company Name

Insurance Policy Number

Insurance Agent Name

Insurance Agent Phone

Phone Number

Extension

Insurance Agent Email

Insurance Agent Address

Address Line 1

City

State

Address Line 2

Zip Code

Country

Insurance Period Start Date

Insurance Period End Date

By checking this box I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Back

Department of Administration

Division of Motor Vehicles

Alaska Motor Vehicle Crash Form 12-209

Crash Information

Your Driver Information

Your Vehicle Information

Crash Description

Other Driver's Information

Other Driver Vehicle Information

Injury Section

Certificate of Insurance

Crash Information

Driver Information

Vehicle Owner Information

Vehicle Information

Insurance Information

Division of Motor Vehicles (DMV)