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The Florida Traffic Crash Report form serves as a crucial document for drivers involved in vehicle accidents within the state. This form is essential for reporting incidents that do not necessitate a law enforcement report, ensuring that all necessary information is communicated effectively. It includes sections for both the driver and vehicle details, such as the year, make, and body type of the vehicle, along with the driver's personal information, including their name, address, and contact numbers. Additionally, the form allows for the inclusion of passengers and witnesses, providing a comprehensive overview of the crash scenario. Notably, it requires the driver to sign and date the report, affirming its accuracy. The form also outlines specific submission guidelines, including options for emailing or mailing the report to the Florida Highway Safety and Motor Vehicles department. Understanding the components of this report is vital for drivers to fulfill their legal obligations and to facilitate any necessary insurance claims.

Form Example

Driver Report of Traffic Crash (Self Report) Driver Exchange of Information

 

HSMV Report Number

 

 

 

 

REPORTING AGENCY CASE NUMBER

DATE OF CRASH

TIME OF CRASH AM PM

 

 

 

 

COUNTY OF CRASH (County Code)

PLACE OR CITY OF CRASH (City Code)

 

Check if

 

 

CRASH OCCURRED ON STREET, ROAD, HIGHWAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Within City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AT STREET ADDRESS #

OR

FEET MILES

N

S

 

E

W

 

AT/ FROM INTERSECTION WITH STREET, ROAD, HIGHWAY

 

 

 

 

OR FROM MILEPOST#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION ONE

 

VEHICLE

 

NON-MOTORIST

 

(optional) EMAIL OWNER/DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

MAKE (Chevy, Ford, Etc.)

 

VEHICLE BODY TYPE (Car, Truck. Etc.)

VEHICLE LICENSE NUMBER

 

STATE

VIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY

 

 

 

 

 

 

 

 

 

 

 

INSURANCE POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF VEHICLE OWNER

(Check if same as Driver)

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF DRIVER (Take From Driver License)/NON-MOTORIST

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

STATE

 

DL TYPE

 

DRIVER/NON-MOTORIST HOME PHONE

DRIVER/NON-MOTORIST BUSINESS PHONE

SEX

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

Area Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION TWO

 

VEHICLE

 

NON-MOTORIST

 

(optional) EMAIL OWNER/DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

MAKE (Chevy, Ford, Etc.)

 

VEHICLE BODY TYPE (Car, Truck. Etc.)

VEHICLE LICENSE NUMBER

 

STATE

VIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY

 

 

 

 

 

 

 

 

 

 

 

INSURANCE POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF VEHICLE OWNER

(Check if same as Driver)

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF DRIVER (Take From Driver License)/NON-MOTORIST

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

STATE

 

DL TYPE

 

DRIVER/NON-MOTORIST HOME PHONE

DRIVER/NON-MOTORIST BUSINESS PHONE

SEX

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

Area Code

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION THREE

 

VEHICLE

 

NON-MOTORIST

 

(optional) EMAIL OWNER/DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

MAKE (Chevy, Ford, Etc.)

 

VEHICLE BODY TYPE (Car, Truck. Etc.)

VEHICLE LICENSE NUMBER

 

STATE

VIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY

 

 

 

 

 

 

 

 

 

 

 

INSURANCE POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF VEHICLE OWNER

(Check if same as Driver)

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF DRIVER (Take From Driver License)/NON-MOTORIST

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

STATE

 

DL TYPE

 

DRIVER/NON-MOTORIST HOME PHONE

DRIVER/NON-MOTORIST BUSINESS PHONE

SEX

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

Area Code

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

 

 

CITY AND STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) NAME

CURRENT ADDRESS

 

 

CITY AND STATE

ZIP CODE

(2) NAME

 

 

CURRENT ADDRESS

CITY AND STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IGNATURE OF DRIVER MAKING REPORT

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

YOU MUST READ AND COMPLY WITH THE INSTRUCTIONS ON THE BACK OF THIS FORM

HSMV 90011S (rev 11/2019)

J

IF YOU WERE TOLD TO COMPLETE AND FORWARD THIS REPORT TO THE DEPARTMENT, PLEASE REFER TO THE FOLLOWING INSTRUCTIONS AND EXAMPLE:

 

 

 

 

 

 

 

HSMV Report Number

 

Driver Report of Traffic Crash (Self Report)

 

 

 

 

 

REPORTING AGENCY CASE NUMBER

DATE OF CRASH

TIME OF CRASH AM PM

Driver Exchange of Information

 

 

 

 

 

01-01-10

11:30

 

 

 

 

 

 

 

COUNTY OF CRASH (County Code)

PLACE OR CITY OF CRASH (City Code)

 

Check if

CRASH OCCURRED ON STREET, ROAD, HIGHWAY

PINELLAS (04)

ST. PETERSBURG (64)

 

Within City

2ND STREET SOUTH

 

 

 

 

 

 

Limits

 

 

 

 

 

 

 

 

 

 

AT STREET ADDRESS # OR

FEET MILES N

S

E W

AT/ FROM INTERSECTION WITH STREET, ROAD, HIGHWAY

 

OR FROM MILEPOST#

0

U.S. 19

SECTION ONE

VEHICLE

NON-MOTORIST (optional) EMAIL OWNER/DRIVER

YEAR

MAKE (Chevy, Ford, Etc.)

 

VEHICLE BODY TYPE (Car, Truck. Etc.)

VEHICLE LICENSE NUMBER

STATE

VIN

 

80

 

FORD

 

 

 

CAR

ABC-123

 

FL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE COMPANY

 

 

 

 

 

 

 

INSURANCE POLICY NUMBER

 

 

 

INSURANCE COMPANY OF FL

 

 

 

 

 

I.C.F. 120000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF VEHICLE OWNER

(Check if same as Driver)

 

 

CURRENT ADDRESS (Number and Street)

CITY AND STATE

ZIP CODE

JOHN DOE

 

 

 

 

 

 

 

1111 FIRST STREET NORTH

PETERSBURG, FL

33731

 

 

 

 

 

 

 

 

 

 

NAME OF DRIVER (Take From Driver License)/NON-MOTORIST

 

 

CURRENT ADDRESS (Number and Street)

CITY AND STATE

ZIP CODE

BILL DOE

 

 

 

 

 

 

 

SAME AS OWNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

STATE

DL TYPE

 

DRIVER/NON-MOTORIST HOME PHONE

DRIVER/NON-MOTORIST BUSINESS PHONE

SEX

DATE OF BIRTH

D 561345706000

 

FL

 

 

 

 

 

 

 

M

01-01-70

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

CITY AND STATE

ZIP CODE

SALLEY DOE

 

 

 

 

 

 

 

SAME AS OWNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF PASSENGER

 

 

 

 

 

CURRENT ADDRESS (Number and Street)

 

 

CITY AND STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective July 1, 2012, Section 316.066(1)(e),Florida Statute, requires that "The driver of a vehicle that was in any manner involved in a crash resulting in damage to a vehicle or other property which does not require a law enforcement report shall, within 10 days after the crash, submit a written report of the crash to the department. The report shall be submitted on a form approved by the department."

•Keep a copy of this report for your records and for insurance purposes.

•Sign the report at the bottom of the front page.

•Submit this via email to SelfReportCrashes@flhsmv.gov, OR;

•Mail this report to: Florida Highway Safety & Motor Vehicles Self Report Crash Team

2900 Apalachee Pkwy, MS 28 Tallahassee, Florida 32399

Please use this space for comments and for listing any witnesses and/or additional passengers, stating which vehicle the passenger was in. For additional vehicles or other involved parties, please add additional front pages for this Driver Report of Traffic Crash.

⇩ Florida Traffic Crash Report File

Document Breakdown

Fact Name Details
Purpose The Florida Traffic Crash Report form is used for drivers to report traffic crashes that do not require law enforcement intervention.
Legal Requirement According to Florida Statute 316.066(1)(e), drivers must submit this report within 10 days if involved in a crash causing property damage.
Submission Methods Reports can be submitted via email to SelfReportCrashes@flhsmv.gov or mailed to the Florida Highway Safety & Motor Vehicles office.
Information Required The form collects details such as driver and vehicle information, crash location, and witness statements.
Record Keeping Drivers are advised to keep a copy of the report for their records and for insurance purposes.
Signature Requirement The driver must sign the report at the bottom of the front page to validate the information provided.
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