CASE NO.

2 2 - 0 0 1 2 6 2 2 6
INVESTIGATOR'S TRAFFIC CRASH REPORT
Mail completed form within 10 days to: Wyoming Department of Transportation
Crash Records
5300 Bishop Boulevard
Cheyenne, WY 82009-3340
Date: yyyy/mm/dd Time (24 hr)
Day of Week Police
Date of Crash (yyyy/mm/dd) Time (24 hr) 2 0 2 2 / 1 2 / 0 2 0 7 : 3 2
Mo Tu We Notified:
Su
2 0 2 2 / 1 2 / 0 2 0 7 : 2 5 Th Fr Sa
Arrived: 2 0 2 2 / 1 2 / 0 2 0 8 : 0 9

EMS
Combined Total Damage Notified: / / :
greater than or equal to Crash Resulting Investigated at Photo/Video
$1,000 Hit & Run from Prior Crash the Scene Photo Video Arrived: / / :
Yes No Yes No Yes No Yes No None Both
EMS Hospital Arrival Time :
Occurred on
Estimated Amount of # non
Private Public/Private
Non-Vehicle Property Damage # Vehicle(s) # Driver(s) # Person(s) Motorists # Injured # Killed
Property Property Damage
Yes No Yes No $ 0 2 0 2 0 3 0 0 0 0 0 0

County GPS Latitude

JOHNSON
City GPS Longitude
4 3
. 8 4 2 6 4 5 5

- 1 0 6
. 6 2 0 4 7 0 7

Highway LRS #
Crash Occurred on: Highway/Street: Milepost Marker

.
CAT. ID # DIR
I 25 / US 87 2 6 3 3 4 5 M L 2 5 D
At Intersection with: Highway/Street:
Occurred on
Incr / Decr
Divided RDway if yes
Incr Decr
Related Intersection: Highway/Street: No Yes
Unknown

INSTRUCTIONS
TO ENSURE ACCURACY
PRINT IN UPPER-CASE LETTERS USING A BLACK OR DARK BLUE PEN!
PRINT NEATLY

A B C D 4 5 6 7 8
If 'Other' is selected in any field, describe in narrative
If a vehicle is towed, describe towed vehicle in narrative

mark if attached SUPPLEMENTAL REPORTS

If more than 2 vehicles are involved, complete form 'Supplemental Additional Vehicle/Driver Form'
If more than 5 persons in a crash, complete form 'Supplemental Additional Vehicle Occupant Information'
Trucks or Commercial Motor Vehicles complete form 'Supplemental Truck/CMV Information'
If a non-motorist is involved, complete form 'Supplemental Non-Motorist'
If a bus is involved and carrying passengers, complete form 'Supplemental Bus Information'
If any drug tests are performed, complete 'Supplemental Drug Test Results'
Previous report submitted
Investigating Agency
01 - City PD 02 - Sheriff 03 - BIA Division
0 6
04 - Forest Service 05 - Campus Police 06 - WHP 07 - Other C (WHP only)
Badge # Officer Name & Rank

1 4 5 E R I C A S A N D S T E A D T R O O P E R
First MI Last Rank
Report Date (yyyy/mm/dd)
2 0 2 2 / 1 2 / 0 2
Signature
Highway Safety Use Only
Proximity to Residence Highway District 2
1-Same Town 2-25 miles or less 3-25 miles Plus 4-Out of State
Date Received: / / Crash Type: G > $1,000 M - Missing Location
N < $1,000 I - Industrial Crash
Report Number: P - Private D - Deliberate

PR902
Revised 01/08/2018
Page 2 Base Information
FIRST HARMFUL EVENT 2 2 Location of FHE 0 1 Weather 1st choice 0 3 Road 1st choice 0 4 Lighting 0 1
01 - On Roadway 01 - Clear 2nd choice 01 - Dry 2nd choice 0 3 01 - Daylight
Non - Collision: 02 - Off Roadway 02 - Raining 02 - Wet 02 - Darkness Unlighted
01 - Overturn/Rollover 03 - Shoulder 03 - Snowing 03 - Ice/Frost 03 - Darkness Lighted
02 - Fire/Explosion 04 - Median 04 - Fog 04 - Snow 04 - Dawn
03 - Immersion 05 - On OTHER Roadway 05 - Blowing Dust/Sand/Dirt 05 - Mud/Dirt/Gravel 05 - Dusk
04 - Jacknife 06 - Outside of ROW 06 - Severe Wind Only 06 - Slush 06 - Other
05 - Cargo/Equipment Loss or Shift 07 - Gore 07 - Blizzard 07 - Oil/Fuel 99 - Unknown
06 - Equipment Failure 08 - Sand on Dry Pavement
08 - Separator 08 - Sleet/Hail/Freezing Rain School Bus
12 - Fell/Jumped from a motor vehicle 0 1
09 - In Parking Lane/Zone 09 - Blowing Snow 09 - Sand on Icy Road
13 - Thrown or Falling Object Related
10 - Tunnel 10 - Cloudy,Overcast 10 - Water standing/Running
16 - Carbon Monoxide (CO) Poisoning
11 - Bridge 11 - Smoke 11 - Other 01 - No
17 - Injuries by being thrown against part of 02 - Yes, Directly Involved
12 - Port of Entry 12 - Other 99 - Unknown
the vehicle 03 - Yes, Indirectly
13 - Rest Area 99 - Unknown
18 - Other Non-Collision (Motorcycle Loss of Involved
99 - Unknown
Control)
Road Circumstance 1st choice Environmental Circumstance 1st choice 0
Collision w/ Person, MV, or Non-Fixed 0 2 1
choose up to 3 choose up to 3
Object: 2nd choice 2nd choice
01 - None 3rd choice 11 - None
3rd choice
19 - Pedestrian 02 - Road Surface Condition 01 - Weather Conditions
20 - Pedacycle 03 - Debris, loose material on the surface 02 - Visual Obstruction Buildings
21 - Railway Vehicle 04 - Ruts, Holes, Bumps 03 - Visual Obstruction Other Vehicle
22 - Motor Vehicle in Transport on Roadway 05 - Work Zone/Construction Zone 04 - Visual Obstruction Vegetation
23 - Motor Vehicle on OTHER Roadway 06 - Worn or Polished Surface 05 - Visual Obstruction Hillcrest
24 - Parked Motor Vehicle 07 - Obstruction in Roadway 06 - Visual Obstruction Embankment-Snow, Rock,etc
26 - Other NON-Fixed Object 08 - Traffic Control Device Missing 07 - Other Physical Obstruction
27 - Work Zone/Maintenance Equipment 09 - Traffic Control Device Inoperative 08 - Glare (Sun or Headlight)
28 - Work Zone Channeling Device 10 - Traffic Control Device Obscured 09 - Animals in Roadway
29 - Object Set in Motion by Another Vehicle 11 - Shoulders (None, Low, Soft, High) 10 - Other
(Single Vehicle Crash) 12 - Non- Highway Work 99 - Unknown
13 - Reduced Road Width
14 - Lane Markings Missing or Faded
15 - Obstructed by a Previous Crash
16 - Other
99 - Unknown
Animals:
Work Zone Related 0 2 Relation to Junction 1 2
30 - Horse 01 - Yes 02 - No 99 - Unknown Non-Interstate Interstate
31 - Cow 01 - Non-Junction 12 - Thru Roadway
32 - Pig Work Zone Workers Present 02 - Intersection 13 - Intersection
33 - Sheep 03 - Intersection Related 14 - Intersection Related
Work Zone Location 04 - Driveway Related
34 - Other Domestic (Dog, Llama, etc) 15 - Ramp
35 - Elk 01 - Before the First Warning Sign 05 - Entrance/Exit Ramp 16 - Other Parts (Gore)
36 - Deer 02 - Advance Warning Area 06 - Railway Grade Crossing 99 - Unknown Interchange
37 - Moose 03 - Transition Area 07 - Crossover Related 07 - Crossover Related
38 - Antelope 04 - Activity Area 08 - Business Entrance
39 - Buffalo 05 - Termination Area 09 - Alley
40 - Other Wild (Bear, Coyote, Eagle) 99 - Unknown 10 - Other Non-Interchange (ie. Bike, Snowmobile Trail, School Xing)
11 - Private Road Junction
Type of Work Zone 99 - Unknown (describe in narrative)
Collision w/ Fixed Object 01 - Lane Closure
02 - Lane Shift or Crossover
Type of Intersection 0 2
41 - Guardrail End 03 - Work on Shoulder/Median 01 - Not an Intersection 06 - Intersection as part
42 - Guardrail Face 04 - Intermittent or Moving Work 02 - Four (4) -Way Intersection of an Interchange
43 - Impact Attenuator/Crash Cushion 05 - Other 03 - T Intersection 07 - Roundabout
44 - Bridge Pier or Support 99 - Unknown 04 - Y Intersection 08 - L Intersection
45 - Bridge Overhead Structure 05 - Five (5) Point or more 09 - Diverging Diamond
Manner of Collision
46 - Bridge Rail 0 7 99 - Unknown
47 - Concrete Traffic Barrier/Jersey Barrier *see diagram right
48 - Other Traffic Barrier (Includes temporary) 01 - Rear End (Front to Rear)
49 - Utility Pole/Light Support 02 - Head On (Front to Front)
50 - Traffic Signal Support 03 - Angle Same Direction (Front to Side)
51 - Traffic Sign Support 04 - Angle (Front-to-Side), Opposing Direction
52 - Overhead Traffic Sign 05 - Angle Right
53 - Sign Support Single Post (Front to Side, includes Broadside)
54 - Sign Support Multiple Post 06 - Angle Direction not Specified
55 - Other Traffic Sign Support 07 - Sideswipe Same Direction (Passing)
56 - Barricade 08 - Sideswipe Opposite Direction (Meeting)
57 - Tree/Shrubbery 09 - Rear to Side (Normally Backing)
58 - Cut Slope 10 - Rear to Rear (Normally Backing)
59 - Road Approach 11 - Rear to Front (Normally Backing)
60 - Rock, Boulder, Rock Slide 12 - Not a Collision w/2 Vehicles in Transport
61 - End of Drainage Pipe/Structure/Culvert 13 - Other
62 - Building or Other Structure Wall 99 - Unknown
63 - Fence (Including Post)
64 - Raised Median or Curb Direction of Force 0 5
65 - Delineator Post
66 - Earth Embankment/Berm 01 - Opposing (Opposite Direction within 15
67 - Ditch degrees)
68 - Snow Embankment 02 - Angle (force exceeds 15 degrees)
03 - Same (same direction within 15 degrees) Manner of Collision CLARIFICATION
69 - Mail Box
70 - Tunnel 04 - Meeting (glancing collision from opposite 01 - Rear End (Front-to-Rear)
71 - Cattle Guard direction) 02 - Head-on (Front-to-Front)
72 - Fixed Object Other 05 - Passing (glancing collision from same
03 - Angle (Front-to-Side), Same Direction
73 - Cable Barrier direction)
99 - Unknown 04 - Angle (Front-to-Side), Opposing Direction
99 - Unknown
05 - Angle (Front-to-Side), Right Angle/Broadside

PR902
Revised 03/07/2017
 Page 3

Indicate North

First Name MI Last Name

1st
Street Number Street Name City: State: Zip Code

Home Work Cell Phone Home Work Cell Phone

and/
Witnesses

- - or - -
First Name MI Last Name
2nd
Street Number Street Name City: State: Zip Code

Home Work Cell Phone Home Work Cell Phone

and/
- - or - -
First Name MI Last Name
3rd
Street Number Street Name City: State: Zip Code

Home Work Cell Phone Home Work Cell Phone

and/
- - or - -
Page4 CASE NO. 2 2 - 0 0 1 2 6 2 2 6
NARRATIVE PAGE
Vehicle 1 was attempting to pass Vehicle 2 failed to maintain its lane of travel and collided with the driver’s side of vehicle 2. The collision forced both
Vehicle 1 and Vehicle 2 off the roadway to the right. Vehicle 2 came to rest in front of Vehicle 1 approximately 3 feet from the right-of-way fence.

Trailer information Vehicle 1

License Plate: 13353T North Dakota
Model year: 2019
VIN:1DW1A5326KBA13464
Registered to: BECO INC
Registered ADDRESS: 3655 COUNTY ROAD 139; NEW SALEM,ND 58563
REGISTRATION EXPIRATION DATE: 2023-12-31

Trailer information Vehicle 2

License Plate: LIC: 3054773 Maine
Model year: 2010
VIN: 1UYVS2531AP897709
Registered to: BEE ZONE LOGISTICS LLC
REGISTRATION ADDRESS: 1451 ELM HILL PIKE STE 315; NASHVILLE,TN 37210
Registration Expiration: 2026-02-28

PR-904
 PR902A
Page 5 Vehicle No. 01 02 03... 0 1 Vehicle Information Revised 03/07/2017
1st event 2 2 Sequence Motor Vehicle Unit Type Vehicle Maneuver/Action
choose up to 4: 0 1 0 1
01 - Motor Vehicle in Transport prior to crash
2nd event 02 - Parked Motor Vehicle 01 - Straight Ahead
3rd event 03 - Working Vehicle/Equipment 02 - Backing
Most Harmful Event
choose 1 2 2 Commercial Motor Vehicle or HM Placard 03 - Changing Lanes
4th event 0 1 04 - Overtaking/Passing
Non-Collision 01 - Yes 02 - No 99 - Unknown
05 - Turning RIght
01 - Overturn/Rollover if yes, complete CMV supplement
06 - Turning Left
02 - Fire/Explosion Vehicle Owner 0 1 07 - Make U-Turn
03 - Immersion 08 - Leaving a Traffic Lane/Parking
01 - Same as Driver 11 - County Law Enforcement
04 - Jacknife 09 - Entering a Traffic Lane
02 - Other 12 - County Fire Department
05 - Cargo/Equipment Loss or Shift 10 - Slowing
03 - Passenger 13 - County Other
06 - Equipment Failure 11 - Negotiating a Curve
04 - Relative 14 - City Law Enforcement
07 - Separation of Units 12 - Parked
05 - Rental Vehicle 15 - City Fire Department
08 - Ran Off the Road Right 13 - Stopped in Traffic
06 - Commercial 16 - City Other
09 - Ran Off the Road Left 14 - Driverless Motor Vehicle
07 - Occupant 17 - Government Other
10 - Cross Median 15 - Trafficway Maintenance
08 - Vehicle Parked 18 - Ambulance/EMS
74 - Cross Centerline 16 - Other
09 - Federal Law Enforcement 19 - WHP
11 - Downhill Runaway 99 - Unknown
10 - Federal Other 20 - State Law Enforc Other
12 - Fell/Jumped from a MV
13 - Thrown or Falling Object Vehicle Type 1 9 Road Surface 0 2 Grade 0 1
14 - Avoiding an Object on Road 01 - Passenger (Not a SUV) 17 - Light Truck ( > 10K) 01 - Concrete 01 - Level
15 - Avoiding an Animal on Road 02 - Passenger Van 18 - Medium Truck (>10K - 26K) 02 - Asphalt 02 - Hillcrest
16 - Carbon Monoxide (CO) Poisoning 03 - PU 19 - Heavy Truck (>26K) 03 - Gravel/Rock 03 - Uphill
17 - Injuries by being thrown against part of vehicle 04 - School Bus 20 - Farm Equipment 04 - Dirt 04 - Downhill
18 - Other Non-Collision (MC Loss of Control) 05 - Other Bus 21 - Construction Vehicle 05 - Brick/Stone 05 - Sag (Bottom)
Collision w/ Person, MV, or Non-Fixed Object 06 - Transit Bus 22 - MC <150 cc 99 - Unknown 99 - Unknown
07 - Charter Bus 23 - Moped
19 - Pedestrian 24 - Snowmobile Horizontal Alignment
20 - Pedacycle 08 - MC >150 cc 0 1
26 - ATV 01 - Straight 03 - Curve Left
21 - Railway Vehicle 09 - Off Road MC
13 - Other Vehicle 27 - MPV 02 - Curve Right 99 - Unknown
22 - Motor Vehicle in Transport on Roadway
23 - Motor Vehicle in Transport on OTHER Roadway 14 - SUV 99 - Unknown Total No. Lanes
24 - Parked Motor Vehicle 15 - Cargo Van 01 - 06, 99 = Unknown
16 - Motor Home 0 4
25 - Struck by Falling, Shifting Cargo or Anything (exclude turn lanes)
Else Set in Motion by Motor Vehicle
(Multi Vehicle Crash) Non -Commercial Trailer Style Traffic Control Working Properly 0 2
26 - Other NON-Fixed Object 01 - No Trailer 07 - Horse/Stock Trailer 01 - Yes 02 - No 99 - Unknown
27 - Work Zone/Maintenance Equipment 02 - Camping Trailer 08 - Motorcycle Trailer
28 - Work Zone Channeling Device 03 - Mobile Home 09 - Multiple Trailers
29 - Object Set in Motion by Another Vehicle
Traffic Control 1 3
04 - Utility Trailer 10 - Other (ie. Bicycle) 01 - None
(Single Vehicle Crash) 05 - Boat/Jet Ski Trailer 99 - Unknown 02 - Stop Sign
06 - Towed Vehicle 03 - Yield Sign
Animals
30 - Horse Underride/Override 04 - Flashing Traffic Signal
0 1 05 - Do Not Enter Sign
31 - Cow 01 - No Underride or Override
32 - Pig 02 - Underride-Compartment Intrusion 06 - Traffic Signal
33 - Sheep 03 - Underride-No Compartment Intrusion 07 - Traffic Signal w/ Ped
34 - Other Domestic (Dog, Llama, ...) 04 - Underride-Compartment Intrusion Unkown 08 - Traffic Signal w/ Ped & Audible Signals
35 - Elk 05 - Override-Motor Vehicle in Transport 09 - Person (Officer/Flagger, Xing Guard, etc)
36 - Deer 06 - Override-Other Motor Vehicle 10 - Pedestrian Crossing
37 - Moose 99 - Unknown if Underride or Override 11 - No Passing Zone
38 - Antelope 12 - Warning Signs
Emergency Vehicle Use 13 - Pavement Markings
39 - Buffalo
01 - Yes 02 - No 99 - Unknown 14 - Traffic Barrels/Cones
40 - Other Wild
Emergency Equipment Activated 15 - Temporary Jersey Barrier
Collision w/ Fixed Object 16 - School Bus Flashing Stop Lamps
41 - Guardrail End 01 - Yes 02 - No 99 - Unknown 17 - School Zone Crossing
42 - Guardrail Face Special Function of MV in Transport 18 - RR Crossing Signal
43 - Impact Attenuator/Crash Cushion 0 1 19 - RR Crossing Signal & Gate
44 - Bridge Pier or Support 01 - None 08 - MV used as School Bus 20 - RR Crossing Cross Buck Sign Only
45 - Bridge Overhead Structure 02 - Police 09 - MV used as Other Bus 21 - RR Crossing Cross Buck with Stop Sign
46 - Bridge Rail 03 - Ambulance/EMS 10 - Construction Equipment 22 - RR Crossing Cross Buck with Yield Sign
47 - Concrete Traffic Barrier/Jersey Barrier 04 - Fire Truck 11 - Farm Equipment 23 - Other
48 - Other Traffic Barrier (Includes temporary) 05 - Military 12 - Taxi 99 - Unknown
49 - Utility Pole/Light Support 06 - Snow Plow 99 - Unknown
50 - Traffic Signal Support 07 - Tow Truck Trafficway Description 0 4
51 - Traffic Sign Support 01 - Two-Way, Not Divided
52 - Overhead Traffic Sign Contributing 1st choice 1 1 02 - Two-Way, Not Divided w/ Continuous
53 - Sign Support Single Post Circumstance Left Turn Lane
54 - Sign Support Multiple Post 2nd choice
01 - None 03 - Two-Way, Divided, Unprotected
55 - Other Traffic Sign Support 02 - Brakes (Painted, >4 Ft) Median
56 - Barricade 03 - Trailer Brakes 04 - Two-Way, Divided, Positive Median Barrier
57 - Tree/Shrubbery 04 - Steering 05 - One-Way Trafficway
58 - Cut Slope 99 - Unknown
05 - Power Train
59 - Road Approach 06 - Suspension Rumble Strips Present 0 1
60 - Rock, Boulder, Rock Slide 07 - Tires
61 - End of Drainage Pipe/Structure/Culvert 08 - Wheels 01 - Yes 02 - No 99 - Unknown
62 - Building or Other Structure Wall 09 - Lights (Head, Signal or Tail)
63 - Fence (Including Post)
Rumble Strips Applicable 0 2
10 - Windows/Windshield
64 - Raised Median or Curb 11 - Rain/Snow/Ice on Windshield 01 - Yes 02 - No 99 - Unknown
65 - Delineator Post 12 - Tinted Windows
66 - Earth Embankment/Berm Rumble Strips 0 5
13 - Vehicle Cargo Blocking View
67 - Ditch 14 - Exhaust System 01 - None
68 - Snow Embankment 15 - Oversized Load 02 - Centerline Rumble Strips
69 - Mail Box 16 - Defroster 03 - Median Shoulder Only
70 - Tunnel 17 - Mirrors 04 - Transverse Rumble Strips (Road Apprch)
71 - Cattle Guard 18 - Wipers 05 - Both Shoulders
72 - Other Fixed Object 19 - Truck Coupling/Trailer Hitch/Safety Chain 06 - Both Centerline and Outside Shoulder
73 - Cable Barrier 20 - Stalled Vehicle 22- Other 07 - Outside Shoulders Only
99 - Unknown 21 - Cruise Control 99-Unknown 99 - Unknown
 Driver/Vehicle Information CASE NO. 2 2 - 0 0 1 2 6 2 2 6
Vehicle No. 01 02 03... 0 1
Last Name First Name MI Gender DOB (yyyy/mm/dd)
K I L W E I N G A R Y M M / /
Street Number Street Name

Mailing Address (PO Box Number) City State Zip Code

-
Occupation Employer
Age
Driver Home Work Cell Phone Home Work Cell Phone SSN (fatals only)
Emp
Phone - - Phone - - - -
Driver's License Number State (FIPS) Restrictions CDL Endorsement
W Y 5 6 B
DL Type 2 DL Class 1 DL Status 1 No. of Vehicle
Occupants
1 - Not Licensed 5 - CDL 1-A 5 - Improper or 1 - Clear 4 - Revoked (01 to 50) 0 1
2 - Driver License 6 - CDL Permit 2-B No Endorsement 2 - Expired 5 - Suspended
3 - Instruction Permit 7 - No License Required 3-C 6 - Other 3 - Canceled or Denied 99 - Unknown Posted Speed Estimated Speed
4 - I2 Permit-intermediate 8 - Restricted License 4-M 7 - None
8 0 3 5
Last Name First Name MI
K I L W E I N G A R Y M
Vehicle Owner same as driver

Street Number Street Name City State Zip Code

Make (ie, Chevrolet, Dodge, Toyota) Model (ie, Silverado, Dakota, Solara) Year Expir. Date (mm/yy)
Initial Impact Most Damaged
I N T E R N A T I O N A L T R U C K T R A C T O R 1 9 9 8 0 9 - 2 3 Point Area
Vehicle Identification Number License Plate No. State (FIPS) Color 0 1 0 1
2 H S F B A S R 1 W C 0 5 7 8 3 8 W Y 5 6 P U R
Insurance N Company Direction of Travel 00 Non-Collision
USI INSURANCE SERVICES LLC 0 5 (Overturn/Rollover)
E-Verified Prior to Crash
Y-Yes Policy # GWP79252J 01-12 (Use 12 Point
01 - North 05 - South Clock Diagram)
Vehicle N-No By MAD TRANSPORTATION 02 - Northeast 06 - Southwest 13 Top (Roof)
Towed Y-Yes 03 - East 07 - West
To CASPER, WY 14 Undercarriage
Y N-No 04 - Southeast 08 - Northwest 99 Unknown
01-Yes 99 - Unknown
Extent of 01 - None 02 - Functional 03 - Minor MV Damage (Can't determine)
0 1 02-No
Damage 0 4 04 - Disabling 99 - Unknown > $1,000 99-Unk.

Driver's Action 1st choice 0 8 Driver's Condition 1st choice 0 1 Citations Issued 1st choice 0 1
(Officer Opinion Only) (Officer Opinion Only) choose up to 5
2nd choice 1 5 2nd choice 2nd choice
01 - No Improper Driving 01 - Apparently Normal 01 - None
3rd choice 02 - Emotional (depressed, angry, disturbed...) 3rd choice
02 - Ran Off Road 02 - DWUI
03 - Failed to Yield ROW 4th choice 03 - ill (Sick) 03 - Drinking - (i.e.,open container)
04 - Disregarded Traffic Signs (e.g. Stop Sign) 04 - Fell Asleep, Fainted 04 - Exceeding Speed Limit
05 - Ran Red Light 05 - Fatigued 05 - Speed too Fast 4th choice
06 - Disregarded Other Road Marking 06 - Under Influence of Medication 06 - Following too Close 5th choice
07 - Speeding 07 - Physical Disability 07 - Wrong Side of Road
08 - Drove too Fast for Conditions 08 - Suspected Drug Use 08 - Improper or No Signal
09 - Improper Turn or No Signal 09 - Suspected Alcohol Use 09 - Improper Lane Use
10 - Improper Backing 10 - Other 10 - Improper Turn
11 - Improper Passing 11 - Driver Inattention 11 - Improper Passing
12 - Improper Parking 99 - Unknown 12 - Improper Starting Out
13 - Wrong Side/Wrong Way Driver's Distraction 13 - Failed to Grant ROW to Ped
14 - Following too Close (Officer Opinion Only) 0 5 14 - Failed to Grant ROW to MV
15 - Failed to Keep Proper Lane 15 - Disregard Officer
16 - Erratic/Reckless/Careless/Aggressive 01 - Not Distracted 16 - Disregard Stop Light
17 - Avoiding an Object on Road 02 - Electronic Communication Device (cell, pager..) 17 - Disregard Stop Sign
18 - Avoiding Animal 03 - Other Electronic Device (palm, TV, computer...) 18 - Disregard Other
19 - Avoiding Non-Motorist 04 - Other Distraction Inside MV (passenger, pet...) 19 - Improper Parking
20 - Avoiding MV 05 - Other Distraction Outside MV 20 - Reckless Driving
21 - Swerve Due to Wind/Slippery Surface 99 - Unknown 21 - Vehicular Homicide
22 - Over Corrected/Over Steered 22 - Driver's License Violation
23 - Evading Law Enforcement 23 - Improper Backing
24 - Other Improper Action 24 - No Insurance
99 - Unknown 25 - Hit & Run
Suspect Suspect Drug Test 26 - Registration Violation
Alcohol Test
Alcohol 0 2
Type
0 1 Drugs 0 2
Type
0 1 27 - Failure to Use Seat Belt
01 - Yes 01 - Yes 28 - Charges Pending
01 - No Test Performed 01 - No Test Performed
02 - No 02 - No 29 - Fed R & R Driver
03 - Test Requested
02 - Test Refused 03 - Test Requested 02 - Test Refused
30 - Fed R & R Vehicle
99 - Unknown 03 - Blood 99 - Unknown 03 - Blood
31 - Racing
If Alcohol Test performed other than 04 - Serum 04 - Serum
If Drug Test performed 32 - Careless
Breath then form 902E will be 05 - Breath 05 - Urine
required with results at a later date. then form 902E will be 33 - Other (explain in narrative)
06 - Urine 06 - Other

.
required with results at 01 - Yes
Alcohol 07 - Other a later date. 99 - Unknown DL Investigation 0 2
Test Result 02 - No
99 - Unknown 99 - Unknown
PR-902A
Revised 01/12/2018
 Page 7 Supplemental Vehicle Occupant Information CASE NO. 2 2 - 0 0 1 2 6 2 2 6
Seat Position Air Bag Deployed Ejection Injury Status Injury Description
01-Driver 01-Not Applicable 01-Not Ejected 01-Fatal Injury 01-Severe Lacerations
02-Front Row Middle 02-Not Deployed 02-Partially Ejected 02-Suspected Serious Injury 02-Broken
03-Front Row Right 03-Deployed Front 03-Totally Ejected 03-Suspected Minor Injury 03-Crushed
04-Passenger Front Row Left 04-Unconsciousness
04-Deployed Side 04-Trapped & 04-Possible Injury
(for foreign or postal vehicles 05-Internal Unknown
where the driver is on the Right) 05-Deployed Combination Extricated 05-No Apparent Injury
06-Lumps
05-Second Row Left 06-Deployed Other 05-Not Applicable 99-Unknown 07-Abrasions
06-Second Row Middle 99-Deployment Unknown 99-Unknown 08-Bruises
07-Second Row Right 09-Minor Lacerations
08-Third Row Left 10-Limping
09-Third Row Middle
11-Pain
10-Third Row Right Occupant Protection Most Injured Area 12-Nausea
11-Fourth Row Left
12-Fourth Row Middle System Operation 01-Head 13-Other (explain in narrative)
13-Fourth Row Right 02-Face 14- No Injury
01-Apparently Normal
14-Other Row (ie. Bus, Van) 03-Neck 99-Unknown
02-Failure/Malfunction
15-Lying Down-Front Seat 03-Misuse 04-Thorax (Chest/Back)
16-Lying Down-Other Seat 05-Abdomen/Pelvis
Injury Classification
17-MC Passenger 04-Air Bag System Turned off
06-Spine 01-Fatal (Not Documented)
18-Sleeper Section of Cab or Rendered Inoperative
07-Upper Extremity (Arm...) 02-Fatal (Autopsy)
19-Other Enclosed Area 99-Unknown
20-Unenclosed Cargo Area 08-Lower Extremity (Leg...) 03-Fatal (Medical Diagnosis)
21-Trailing Unit 09-No Injury 04-Non-Fatal (Hospitalized
97-Riding on MV Exterior Seat Belt Usage 99-Unknown overnight or longer)
98-Other (explain in narrative) 01-None Used 05-Non-Fatal (Treated &
99-Unknown Released from Hospital)
02-Not Available
06-First Aid Given at Scene
MV # Person Type 03-Shoulder & Lap Belt
04-Shoulder Belt Only 07-No Treatment
01 01-Driver 08-Refused Treatment
05-Lap Belt Only
02 02-Passenger 99-Unknown
06-Passive Restraint Only
Occupant Protection
03 99-Unknown
07-Restraint Used-Type Unk.
04 Inj. Transported by
System Operation
If non-motorist, complete

Most Injured Area

Air Bag Deployed
08-Forward Facing Child
05... supplemental form

Transported by
09-Rear Facing Child Restraint 01-Not Transported

Injury Status
10-Booster Seat

Classication
02-EMS (Ground)

Description
11-Child Restraint-Type Unk. 03-EMS (Air)
Seat Belt
Position

Ejection
12-Helmet Used

Injured
Person

04-Law Enforcement
Usage

Injury

Injury
Type:

13-Other
MV #

05-Other (Private MV)

Seat

99-Unknown EMS ID EMS Run # 99-Unknown

Driver EMS ID EMS Run # Medical Facility

01 01 01 03 01 02 01 05 09 14 07 01

Occupant Information
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
 CASE NO. 2 2 - 0 0 1 2 6 2 2 6

Supplemental Truck/CMV Information

GVW 0 3
Combination GVW
01 - Commercial Vehicle
02 - Non-Commercial Vehicle 0 1 01 - 10,000 lbs or less
02 - 10,001 to 26,000 lbs
Vehicle Number 01 02 03 04 05 ... 0 1 03 - More than 26,000 lbs

Driver Last Name Driver First Name MI

K I L W E I N G A R Y M
ICC/MC No. US DOT No.
7 4 7 0 8 7 1 7 1 8 8 1 4 No. Axles
02-98 or 99 for unknown 0 5

Carrier's Name
K I L W E I N T R U C K I N G

Carrier's Street Street Address or PO Box of Individual,

Number Carrier's Street Name Partnership, or Corporation
P O B O X 1 4 7 3

City
E V A N S V I L L E

State Zip Code Carrier's Country

W Y 8 2 6 3 6 - U S A

Commercial Cargo Body Type 0 3 Commercial Cargo 0 2 Commercial MV Configuration 0 6

01 - No Cargo Body 01 - Not Applicable 01 - Passenger Vehicles Carrying Hazardous Materials
02 - Bus (Light MV w/o HM Placard or Bobtail) 02 - Single-Unit Truck (2 axle and GVWR more than
03 - Van/Enclosed Box 02 - General Freight 10,000 lbs)
04 - Hopper (grain/chips/Benonite) 03 - Household Goods 03 - Single-Unit Truck (3 or more axles)
05 - Pole 04 - Heavy Machinery 04 - Truck Pulling Trailer(s)
06 - Cargo Tank 05 - Motor Vehicles 05 - Truck Tractor Only (Bobtail)
07 - Flatbed 06 - Gases in Bulk 06 - Truck Tractor/Semi-Trailer
08 - Dump (Belly, Side, or Tail Dump) 07 - Livestock 07 - Truck Tractor/Double Trailer
09 - Concrete Mixer 08 - Solids in Bulk 08 - Truck Tractor/Triple Trailer (illegal in WY)
10 - Auto Transporter 09 - Liquids in Bulk 09 - Truck - Can't Classify (More than 10,000 lbs GVWR)
11 - Tow Truck 10 - Explosives 99 - Unknown
12 - Garbage/Refuse 11 - Other Hazardous Materials
13 - Snowplow 12 - Empty
14 - Livestock 13 - Refrigerated Foods
15 - Drilling Equipment 14 - Other
16 - Other Truck 99 - Unknown
17 - Logging
18 - Intermodal
99 - Unknown

.
.
HM Placard 0 2 HM Cargo Spill 0 2 HM Placard Class 1st 1 1
01 - Class 1 Explosives

.
01 - Yes, (If yes continue on) 01 - Yes 2nd 1 1
02 - No 02 - No 02 - Class 2 Gases (Flammable, Non-
99 - Unknown 99 - Unknown Flammable, Poison and Toxic) 3rd 1 1
03 - Class 3 Flammable Liquids
04 - Class 4 Flammable Solids
05 - Class 5 Oxidizers & Organic Peroxides
06 - Class 6 Poisonous & Toxic
07 - Class 7 Radioactive Materials
08 - Class 8 Corrosives
HM Placard ID No. 1 09 - Class 9 Miscellaneous Hazardous Materials
10 - Other Placards (Dangerous Mixed
HM Placard ID No. 2 Loads, Hot Markings)
11 - Not Applicable
HM Placard ID No. 3 99 - Unknown

PR-902B
Revised 04/07/15
 PR902A
Page 9 Vehicle No. 01 02 03... 0 2 Vehicle Information Revised 03/07/2017
1st event 2 2 Sequence Motor Vehicle Unit Type Vehicle Maneuver/Action
choose up to 4: 0 1 0 1
01 - Motor Vehicle in Transport prior to crash
2nd event 02 - Parked Motor Vehicle 01 - Straight Ahead
3rd event 03 - Working Vehicle/Equipment 02 - Backing
Most Harmful Event
choose 1 2 2 Commercial Motor Vehicle or HM Placard 03 - Changing Lanes
4th event 0 1 04 - Overtaking/Passing
Non-Collision 01 - Yes 02 - No 99 - Unknown
05 - Turning RIght
01 - Overturn/Rollover if yes, complete CMV supplement
06 - Turning Left
02 - Fire/Explosion Vehicle Owner 0 2 07 - Make U-Turn
03 - Immersion 08 - Leaving a Traffic Lane/Parking
01 - Same as Driver 11 - County Law Enforcement
04 - Jacknife 09 - Entering a Traffic Lane
02 - Other 12 - County Fire Department
05 - Cargo/Equipment Loss or Shift 10 - Slowing
03 - Passenger 13 - County Other
06 - Equipment Failure 11 - Negotiating a Curve
04 - Relative 14 - City Law Enforcement
07 - Separation of Units 12 - Parked
05 - Rental Vehicle 15 - City Fire Department
08 - Ran Off the Road Right 13 - Stopped in Traffic
06 - Commercial 16 - City Other
09 - Ran Off the Road Left 14 - Driverless Motor Vehicle
07 - Occupant 17 - Government Other
10 - Cross Median 15 - Trafficway Maintenance
08 - Vehicle Parked 18 - Ambulance/EMS
74 - Cross Centerline 16 - Other
09 - Federal Law Enforcement 19 - WHP
11 - Downhill Runaway 99 - Unknown
10 - Federal Other 20 - State Law Enforc Other
12 - Fell/Jumped from a MV
13 - Thrown or Falling Object Vehicle Type 1 9 Road Surface 0 2 Grade 0 1
14 - Avoiding an Object on Road 01 - Passenger (Not a SUV) 17 - Light Truck ( > 10K) 01 - Concrete 01 - Level
15 - Avoiding an Animal on Road 02 - Passenger Van 18 - Medium Truck (>10K - 26K) 02 - Asphalt 02 - Hillcrest
16 - Carbon Monoxide (CO) Poisoning 03 - PU 19 - Heavy Truck (>26K) 03 - Gravel/Rock 03 - Uphill
17 - Injuries by being thrown against part of vehicle 04 - School Bus 20 - Farm Equipment 04 - Dirt 04 - Downhill
18 - Other Non-Collision (MC Loss of Control) 05 - Other Bus 21 - Construction Vehicle 05 - Brick/Stone 05 - Sag (Bottom)
Collision w/ Person, MV, or Non-Fixed Object 06 - Transit Bus 22 - MC <150 cc 99 - Unknown 99 - Unknown
07 - Charter Bus 23 - Moped
19 - Pedestrian 24 - Snowmobile Horizontal Alignment
20 - Pedacycle 08 - MC >150 cc 0 1
26 - ATV 01 - Straight 03 - Curve Left
21 - Railway Vehicle 09 - Off Road MC
13 - Other Vehicle 27 - MPV 02 - Curve Right 99 - Unknown
22 - Motor Vehicle in Transport on Roadway
23 - Motor Vehicle in Transport on OTHER Roadway 14 - SUV 99 - Unknown Total No. Lanes
24 - Parked Motor Vehicle 15 - Cargo Van 01 - 06, 99 = Unknown
16 - Motor Home 0 4
25 - Struck by Falling, Shifting Cargo or Anything (exclude turn lanes)
Else Set in Motion by Motor Vehicle
(Multi Vehicle Crash) Non -Commercial Trailer Style Traffic Control Working Properly 0 2
26 - Other NON-Fixed Object 01 - No Trailer 07 - Horse/Stock Trailer 01 - Yes 02 - No 99 - Unknown
27 - Work Zone/Maintenance Equipment 02 - Camping Trailer 08 - Motorcycle Trailer
28 - Work Zone Channeling Device 03 - Mobile Home 09 - Multiple Trailers
29 - Object Set in Motion by Another Vehicle
Traffic Control 1 3
04 - Utility Trailer 10 - Other (ie. Bicycle) 01 - None
(Single Vehicle Crash) 05 - Boat/Jet Ski Trailer 99 - Unknown 02 - Stop Sign
06 - Towed Vehicle 03 - Yield Sign
Animals
30 - Horse Underride/Override 04 - Flashing Traffic Signal
0 1 05 - Do Not Enter Sign
31 - Cow 01 - No Underride or Override
32 - Pig 02 - Underride-Compartment Intrusion 06 - Traffic Signal
33 - Sheep 03 - Underride-No Compartment Intrusion 07 - Traffic Signal w/ Ped
34 - Other Domestic (Dog, Llama, ...) 04 - Underride-Compartment Intrusion Unkown 08 - Traffic Signal w/ Ped & Audible Signals
35 - Elk 05 - Override-Motor Vehicle in Transport 09 - Person (Officer/Flagger, Xing Guard, etc)
36 - Deer 06 - Override-Other Motor Vehicle 10 - Pedestrian Crossing
37 - Moose 99 - Unknown if Underride or Override 11 - No Passing Zone
38 - Antelope 12 - Warning Signs
Emergency Vehicle Use 13 - Pavement Markings
39 - Buffalo
01 - Yes 02 - No 99 - Unknown 14 - Traffic Barrels/Cones
40 - Other Wild
Emergency Equipment Activated 15 - Temporary Jersey Barrier
Collision w/ Fixed Object 16 - School Bus Flashing Stop Lamps
41 - Guardrail End 01 - Yes 02 - No 99 - Unknown 17 - School Zone Crossing
42 - Guardrail Face Special Function of MV in Transport 18 - RR Crossing Signal
43 - Impact Attenuator/Crash Cushion 0 1 19 - RR Crossing Signal & Gate
44 - Bridge Pier or Support 01 - None 08 - MV used as School Bus 20 - RR Crossing Cross Buck Sign Only
45 - Bridge Overhead Structure 02 - Police 09 - MV used as Other Bus 21 - RR Crossing Cross Buck with Stop Sign
46 - Bridge Rail 03 - Ambulance/EMS 10 - Construction Equipment 22 - RR Crossing Cross Buck with Yield Sign
47 - Concrete Traffic Barrier/Jersey Barrier 04 - Fire Truck 11 - Farm Equipment 23 - Other
48 - Other Traffic Barrier (Includes temporary) 05 - Military 12 - Taxi 99 - Unknown
49 - Utility Pole/Light Support 06 - Snow Plow 99 - Unknown
50 - Traffic Signal Support 07 - Tow Truck Trafficway Description 0 4
51 - Traffic Sign Support 01 - Two-Way, Not Divided
52 - Overhead Traffic Sign Contributing 1st choice 0 1 02 - Two-Way, Not Divided w/ Continuous
53 - Sign Support Single Post Circumstance Left Turn Lane
54 - Sign Support Multiple Post 2nd choice
01 - None 03 - Two-Way, Divided, Unprotected
55 - Other Traffic Sign Support 02 - Brakes (Painted, >4 Ft) Median
56 - Barricade 03 - Trailer Brakes 04 - Two-Way, Divided, Positive Median Barrier
57 - Tree/Shrubbery 04 - Steering 05 - One-Way Trafficway
58 - Cut Slope 99 - Unknown
05 - Power Train
59 - Road Approach 06 - Suspension Rumble Strips Present 0 1
60 - Rock, Boulder, Rock Slide 07 - Tires
61 - End of Drainage Pipe/Structure/Culvert 08 - Wheels 01 - Yes 02 - No 99 - Unknown
62 - Building or Other Structure Wall 09 - Lights (Head, Signal or Tail)
63 - Fence (Including Post)
Rumble Strips Applicable 0 2
10 - Windows/Windshield
64 - Raised Median or Curb 11 - Rain/Snow/Ice on Windshield 01 - Yes 02 - No 99 - Unknown
65 - Delineator Post 12 - Tinted Windows
66 - Earth Embankment/Berm Rumble Strips 0 5
13 - Vehicle Cargo Blocking View
67 - Ditch 14 - Exhaust System 01 - None
68 - Snow Embankment 15 - Oversized Load 02 - Centerline Rumble Strips
69 - Mail Box 16 - Defroster 03 - Median Shoulder Only
70 - Tunnel 17 - Mirrors 04 - Transverse Rumble Strips (Road Apprch)
71 - Cattle Guard 18 - Wipers 05 - Both Shoulders
72 - Other Fixed Object 19 - Truck Coupling/Trailer Hitch/Safety Chain 06 - Both Centerline and Outside Shoulder
73 - Cable Barrier 20 - Stalled Vehicle 22- Other 07 - Outside Shoulders Only
99 - Unknown 21 - Cruise Control 99-Unknown 99 - Unknown
 Driver/Vehicle Information CASE NO. 2 2 - 0 0 1 2 6 2 2 6
Vehicle No. 01 02 03... 0 2
Last Name First Name MI Gender DOB (yyyy/mm/dd)
P A G A N S A N C H E Z L U I S A M / /
Street Number Street Name

Mailing Address (PO Box Number) City State Zip Code

-
Occupation Employer
Age
Driver Home Work Cell Phone Home Work Cell Phone SSN (fatals only)
Emp
Phone - - Phone - - - -
Driver's License Number State (FIPS) Restrictions CDL Endorsement
F L 1 2 A
DL Type 2 DL Class 1 DL Status 1 No. of Vehicle
Occupants
1 - Not Licensed 5 - CDL 1-A 5 - Improper or 1 - Clear 4 - Revoked (01 to 50) 0 2
2 - Driver License 6 - CDL Permit 2-B No Endorsement 2 - Expired 5 - Suspended
3 - Instruction Permit 7 - No License Required 3-C 6 - Other 3 - Canceled or Denied 99 - Unknown Posted Speed Estimated Speed
4 - I2 Permit-intermediate 8 - Restricted License 4-M 7 - None
8 0 3 0
Last Name First Name MI
T R U C K I N G I N C K A R D A N
Vehicle Owner same as driver

Street Number Street Name City State Zip Code

Make (ie, Chevrolet, Dodge, Toyota) Model (ie, Silverado, Dakota, Solara) Year Expir. Date (mm/yy)
Initial Impact Most Damaged
P E T E R B U I L T T R U C K T R A C T O R 2 0 2 3 0 6 - 2 3 Point Area
Vehicle Identification Number License Plate No. State (FIPS) Color 0 8 0 8
1 X P B D P 9 X 5 P D 8 3 7 1 0 7 I N 1 8 W H T
Insurance N Company Direction of Travel 00 Non-Collision
NATIONAL CONTINENTAL 0 5 (Overturn/Rollover)
E-Verified Prior to Crash
Y-Yes Policy # CIN 000-5934-234-2 01-12 (Use 12 Point
01 - North 05 - South Clock Diagram)
Vehicle N-No By UNKNOWN 02 - Northeast 06 - Southwest 13 Top (Roof)
Towed Y-Yes 03 - East 07 - West
To ARRANGMETNS MADE BY DRIVER 14 Undercarriage
Y N-No 04 - Southeast 08 - Northwest 99 Unknown
01-Yes 99 - Unknown
Extent of 01 - None 02 - Functional 03 - Minor MV Damage (Can't determine)
0 1 02-No
Damage 0 4 04 - Disabling 99 - Unknown > $1,000 99-Unk.

Driver's Action 1st choice 0 1 Driver's Condition 1st choice 0 1 Citations Issued 1st choice 0 1
(Officer Opinion Only) (Officer Opinion Only) choose up to 5
2nd choice 2nd choice 2nd choice
01 - No Improper Driving 01 - Apparently Normal 01 - None
3rd choice 02 - Emotional (depressed, angry, disturbed...) 3rd choice
02 - Ran Off Road 02 - DWUI
03 - Failed to Yield ROW 4th choice 03 - ill (Sick) 03 - Drinking - (i.e.,open container)
04 - Disregarded Traffic Signs (e.g. Stop Sign) 04 - Fell Asleep, Fainted 04 - Exceeding Speed Limit
05 - Ran Red Light 05 - Fatigued 05 - Speed too Fast 4th choice
06 - Disregarded Other Road Marking 06 - Under Influence of Medication 06 - Following too Close 5th choice
07 - Speeding 07 - Physical Disability 07 - Wrong Side of Road
08 - Drove too Fast for Conditions 08 - Suspected Drug Use 08 - Improper or No Signal
09 - Improper Turn or No Signal 09 - Suspected Alcohol Use 09 - Improper Lane Use
10 - Improper Backing 10 - Other 10 - Improper Turn
11 - Improper Passing 11 - Driver Inattention 11 - Improper Passing
12 - Improper Parking 99 - Unknown 12 - Improper Starting Out
13 - Wrong Side/Wrong Way Driver's Distraction 13 - Failed to Grant ROW to Ped
14 - Following too Close (Officer Opinion Only) 0 1 14 - Failed to Grant ROW to MV
15 - Failed to Keep Proper Lane 15 - Disregard Officer
16 - Erratic/Reckless/Careless/Aggressive 01 - Not Distracted 16 - Disregard Stop Light
17 - Avoiding an Object on Road 02 - Electronic Communication Device (cell, pager..) 17 - Disregard Stop Sign
18 - Avoiding Animal 03 - Other Electronic Device (palm, TV, computer...) 18 - Disregard Other
19 - Avoiding Non-Motorist 04 - Other Distraction Inside MV (passenger, pet...) 19 - Improper Parking
20 - Avoiding MV 05 - Other Distraction Outside MV 20 - Reckless Driving
21 - Swerve Due to Wind/Slippery Surface 99 - Unknown 21 - Vehicular Homicide
22 - Over Corrected/Over Steered 22 - Driver's License Violation
23 - Evading Law Enforcement 23 - Improper Backing
24 - Other Improper Action 24 - No Insurance
99 - Unknown 25 - Hit & Run
Suspect Suspect Drug Test 26 - Registration Violation
Alcohol Test
Alcohol 0 2
Type
0 1 Drugs 0 2
Type
0 1 27 - Failure to Use Seat Belt
01 - Yes 01 - Yes 28 - Charges Pending
01 - No Test Performed 01 - No Test Performed
02 - No 02 - No 29 - Fed R & R Driver
03 - Test Requested
02 - Test Refused 03 - Test Requested 02 - Test Refused
30 - Fed R & R Vehicle
99 - Unknown 03 - Blood 99 - Unknown 03 - Blood
31 - Racing
If Alcohol Test performed other than 04 - Serum 04 - Serum
If Drug Test performed 32 - Careless
Breath then form 902E will be 05 - Breath 05 - Urine
required with results at a later date. then form 902E will be 33 - Other (explain in narrative)
06 - Urine 06 - Other

.
required with results at 01 - Yes
Alcohol 07 - Other a later date. 99 - Unknown DL Investigation 0 2
Test Result 02 - No
99 - Unknown 99 - Unknown
PR-902A
Revised 01/12/2018
 Page 11 Supplemental Vehicle Occupant Information CASE NO. 2 2 - 0 0 1 2 6 2 2 6
Seat Position Air Bag Deployed Ejection Injury Status Injury Description
01-Driver 01-Not Applicable 01-Not Ejected 01-Fatal Injury 01-Severe Lacerations
02-Front Row Middle 02-Not Deployed 02-Partially Ejected 02-Suspected Serious Injury 02-Broken
03-Front Row Right 03-Deployed Front 03-Totally Ejected 03-Suspected Minor Injury 03-Crushed
04-Passenger Front Row Left 04-Unconsciousness
04-Deployed Side 04-Trapped & 04-Possible Injury
(for foreign or postal vehicles 05-Internal Unknown
where the driver is on the Right) 05-Deployed Combination Extricated 05-No Apparent Injury
06-Lumps
05-Second Row Left 06-Deployed Other 05-Not Applicable 99-Unknown 07-Abrasions
06-Second Row Middle 99-Deployment Unknown 99-Unknown 08-Bruises
07-Second Row Right 09-Minor Lacerations
08-Third Row Left 10-Limping
09-Third Row Middle
11-Pain
10-Third Row Right Occupant Protection Most Injured Area 12-Nausea
11-Fourth Row Left
12-Fourth Row Middle System Operation 01-Head 13-Other (explain in narrative)
13-Fourth Row Right 02-Face 14- No Injury
01-Apparently Normal
14-Other Row (ie. Bus, Van) 03-Neck 99-Unknown
02-Failure/Malfunction
15-Lying Down-Front Seat 03-Misuse 04-Thorax (Chest/Back)
16-Lying Down-Other Seat 05-Abdomen/Pelvis
Injury Classification
17-MC Passenger 04-Air Bag System Turned off
06-Spine 01-Fatal (Not Documented)
18-Sleeper Section of Cab or Rendered Inoperative
07-Upper Extremity (Arm...) 02-Fatal (Autopsy)
19-Other Enclosed Area 99-Unknown
20-Unenclosed Cargo Area 08-Lower Extremity (Leg...) 03-Fatal (Medical Diagnosis)
21-Trailing Unit 09-No Injury 04-Non-Fatal (Hospitalized
97-Riding on MV Exterior Seat Belt Usage 99-Unknown overnight or longer)
98-Other (explain in narrative) 01-None Used 05-Non-Fatal (Treated &
99-Unknown Released from Hospital)
02-Not Available
06-First Aid Given at Scene
MV # Person Type 03-Shoulder & Lap Belt
04-Shoulder Belt Only 07-No Treatment
01 01-Driver 08-Refused Treatment
05-Lap Belt Only
02 02-Passenger 99-Unknown
06-Passive Restraint Only
Occupant Protection
03 99-Unknown
07-Restraint Used-Type Unk.
04 Inj. Transported by
System Operation
If non-motorist, complete

Most Injured Area

Air Bag Deployed
08-Forward Facing Child
05... supplemental form

Transported by
09-Rear Facing Child Restraint 01-Not Transported

Injury Status
10-Booster Seat

Classication
02-EMS (Ground)

Description
11-Child Restraint-Type Unk. 03-EMS (Air)
Seat Belt
Position

Ejection
12-Helmet Used

Injured
Person

04-Law Enforcement
Usage

Injury

Injury
Type:

13-Other
MV #

05-Other (Private MV)

Seat

99-Unknown EMS ID EMS Run # 99-Unknown

Driver EMS ID EMS Run # Medical Facility

02 01 01 03 01 02 01 05 09 14 07 01

Occupant Information
yyyy/mm/dd
Last First
Name T E J A D A T O R R E S Name L E O M A R I S MI DOB / / Age
SSN (Fatals Only) : Gender
02 02 03 03 - - 01 02 01 05 09 14 07 01 M, F, X F
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
yyyy/mm/dd
Last First
Name Name MI DOB / / Age
SSN (Fatals Only) : Gender
- - M, F, X
Home Work Cell Phone Home Work Cell Phone
and/
- - or - - Medical Facility
 CASE NO. 2 2 - 0 0 1 2 6 2 2 6

Supplemental Truck/CMV Information

GVW 0 3
Combination GVW
01 - Commercial Vehicle
02 - Non-Commercial Vehicle 0 1 01 - 10,000 lbs or less
02 - 10,001 to 26,000 lbs
Vehicle Number 01 02 03 04 05 ... 0 2 03 - More than 26,000 lbs

Driver Last Name Driver First Name MI

P A G A N S A N C H E Z L U I S A
ICC/MC No. US DOT No.
1 3 0 7 0 8 3 3 7 1 7 3 8 2 No. Axles
02-98 or 99 for unknown 0 5

Carrier's Name
A B 1 C A R R I E R S I N C

Carrier's Street Street Address or PO Box of Individual,

Number Carrier's Street Name Partnership, or Corporation
1 4 1 0 W S O U T H S T

City
B L U F F T O N

State Zip Code Carrier's Country

I N 4 6 7 1 4 - U S A

Commercial Cargo Body Type 0 3 Commercial Cargo 0 2 Commercial MV Configuration 0 6

01 - No Cargo Body 01 - Not Applicable 01 - Passenger Vehicles Carrying Hazardous Materials
02 - Bus (Light MV w/o HM Placard or Bobtail) 02 - Single-Unit Truck (2 axle and GVWR more than
03 - Van/Enclosed Box 02 - General Freight 10,000 lbs)
04 - Hopper (grain/chips/Benonite) 03 - Household Goods 03 - Single-Unit Truck (3 or more axles)
05 - Pole 04 - Heavy Machinery 04 - Truck Pulling Trailer(s)
06 - Cargo Tank 05 - Motor Vehicles 05 - Truck Tractor Only (Bobtail)
07 - Flatbed 06 - Gases in Bulk 06 - Truck Tractor/Semi-Trailer
08 - Dump (Belly, Side, or Tail Dump) 07 - Livestock 07 - Truck Tractor/Double Trailer
09 - Concrete Mixer 08 - Solids in Bulk 08 - Truck Tractor/Triple Trailer (illegal in WY)
10 - Auto Transporter 09 - Liquids in Bulk 09 - Truck - Can't Classify (More than 10,000 lbs GVWR)
11 - Tow Truck 10 - Explosives 99 - Unknown
12 - Garbage/Refuse 11 - Other Hazardous Materials
13 - Snowplow 12 - Empty
14 - Livestock 13 - Refrigerated Foods
15 - Drilling Equipment 14 - Other
16 - Other Truck 99 - Unknown
17 - Logging
18 - Intermodal
99 - Unknown

.
.
HM Placard 0 2 HM Cargo Spill 0 2 HM Placard Class 1st 1 1
01 - Class 1 Explosives

.
01 - Yes, (If yes continue on) 01 - Yes 2nd 1 1
02 - No 02 - No 02 - Class 2 Gases (Flammable, Non-
99 - Unknown 99 - Unknown Flammable, Poison and Toxic) 3rd 1 1
03 - Class 3 Flammable Liquids
04 - Class 4 Flammable Solids
05 - Class 5 Oxidizers & Organic Peroxides
06 - Class 6 Poisonous & Toxic
07 - Class 7 Radioactive Materials
08 - Class 8 Corrosives
HM Placard ID No. 1 09 - Class 9 Miscellaneous Hazardous Materials
10 - Other Placards (Dangerous Mixed
HM Placard ID No. 2 Loads, Hot Markings)
11 - Not Applicable
HM Placard ID No. 3 99 - Unknown

PR-902B
Revised 04/07/15