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Fill in Your Mississippi Accident Report Template

The Mississippi Accident Report form is a crucial document used to record details about vehicle accidents within the state. This form captures essential information, such as the time and location of the incident, involved parties, and any injuries sustained. If you've been in an accident, filling out this form accurately is vital—click the button below to get started.

Make This Mississippi Accident Report

Make This Mississippi Accident Report

Content Overview

The Mississippi Accident Report form is a critical document designed to capture essential details following a vehicle accident. This form is utilized by law enforcement agencies to record specific information about the incident, including the date and time of the accident, the involved vehicles, and the status of individuals affected. Key sections of the form require details about the vehicles, such as make, model, and license plate numbers, as well as information about the drivers and passengers, including their names, addresses, and any injuries sustained. Witness information is also collected, which can be vital for investigations. Additionally, the form includes fields for documenting the crash's circumstances, such as weather conditions, road types, and any contributing factors like impaired driving or mechanical failures. By meticulously filling out this report, officers provide a comprehensive account that serves not only for legal purposes but also for insurance claims and future safety measures. Understanding the components of this form can help individuals navigate the often complex aftermath of an accident with greater confidence.

Mississippi Accident Report Preview

STATE OF MISSISSIPPI UNIFORM CRASH REPORT

Agency Number

Agency Case Number

Page

0 1

Agency Name	G1. County

G2. Status Code

C P U

G3. Reported Date (MM/DD/YYYY)

/ /

G4. Reported Time (2400)

G5. Officer Time

Arrival Time (2400)						10-24 Time (2400)

G6. Vehicles			G7. Killed			G8. Injured

G9. Address Number

G10. Street Name

G11. Hwy/County Road #

G12. Trafficflow Direction

G13. Int.

G14. Distance

. M

G15. Direction

N E

S W

G16. Intersecting Street Name

G17. Int. Hwy/County Road #

G18. City Name

G19. Latitude

G20. Longitude

G21. First Harmful Event

Crash with OMV in road:

Rear end slow or stop

Rear end turn

Left turn same roadway Left turn cross traffic

Right turn cross traffic

Head on

Sideswipe

Angle

Hit and run

Non-Crash in Road

Overturn

Jackknife

Fell from vehicle

Other

Crash of MV in road with:

Pedestrian

Parked Vehicle

Train

Bicyclist

Deer

Animal (other than deer)

Fixed Object
Bridge/Culvert		Roadway		None
Bridge/Culvert
Embankment/Ditch/Curb	Location	Off-Roadway		Four-way Inter
Guardrail/Median Barrier		Median		T - Intersection
				Crossover
Tree	Crash	Roadside	Type	Crossover
Tree		Roadside
Utility pole/light support		Shoulder		Driveway

	G22.
			Intersection
Other fixed object				Five-point or more
Other fixed object		Parking Lot
		Parking Lot
Sign Post				Off Ramp
Signal standard		Gore		On Ramp
Signal standard			G23.	On Ramp
			G23.	Path/Trail
Non-fixed Object				Path/Trail
Non-fixed Object
Building/Other Structure				RR Xing
				RR Xing
Maint. Equip. - Not Moving				Traffic Circle/Round
				Traffic Circle/Round
Maint. Equip. - Moving
Other non-fixed object				Y - Intersection
Other non-fixed object

G24. Roadway System

City Street

State Highway

U.S. Highway

County Road

Parking Lot/Private Drive

Interstate

Off Road

State Park

	Daylight		Dry	Condition(2)
Condition	Daylight	Condition
Condition	Dark-Lit	Condition	Wet
			Wet
			Water
			Water
LightG25.	Dark-Unlit	RoadG26.	Sand/Mud/Dirt/Oil/Gravel	WeatherG27.
LightG25.	D a w n	RoadG26.	Ice	WeatherG27.
			Ice

			Slush
	Dusk		Snow
			Snow

Clear	Blown Debris	Relationship
			Not Workzone Related
Rain	Fog/Smog/Smoke

		Workzone	Within Construction Zone
Cloudy	Sleet/Hail		Advance Warning Area
Cloudy	Sleet/Hail


High winds	Snow	G28.
High winds	Snow	G28.

WITNESS(ES)

G29. Workzone Type (2)

None

Intermittent or Moving Work Lane Closure

Lane Shift/Crossover

Shoulder/Median Work

Utility

G30.	First Name			MI	Last Name
G31.	Address					G32. Phone Number
G33.	City				G34.	State	G35. Zip Code
	G36. Sex	M	F				G37. Age

G38.	First Name			MI	Last Name
G39.	Address						G40. Phone Number
							G40. Phone Number
G41.	City				G42.	State	G43.	Zip Code
	G44. Sex	M	F			G45. Age

G47. Investigating Officer Name (Please Print)

G48. Officer Signature

G46.

Badge Number

G49.

Reviewing Badge Number

G50. Reviewing Officer Initials

G51. Photos Taken

G52. Photographer and Badge #

Y N

4479140593

MUCR

Diagram/Narrative

Agency Number

Agency Case Number

N1. Collision Diagram

Page 0 2 of

North

Arrow

N2. Collision Narrative

1772140596

MUCR

Person/Occupant

V0. Veh. # P0. Person #: Agency Number

Agency Case Number

Page

P1. Person Type

Driver

Pedestrian

Bicyclist

Skater

Other non-motorist

Train Engineer

Hit and Run Driver

P2.

License #

P3. State

P4. CDL?

P5. DOB (MM/DD/YYYY)

Shoulder & Lap Belt

Type

None

Complaint of Pain

None

StatusDLP12.

Suspended

Other

SafetyEquip. (2)

EjectionP24.P23. Injury

Totally

Helmet

P6.

First Name

Last Name

Lap Belt

Serious

Valid

Suspended - DUI

Life Threatening

Automated Restraint

Killed

P7. Address

P8. Phone Number

No License

Learner Permit

Shoulder Belt

Not

Expired

Improper DL

Child Safety Seat

Partially

P9.

City

P10. State

P11.

Zip Code

P14.Ticket #

Offense

Extricated

P13.Cited

Sex

White

Hispanic

P15.

Race

Xport

Not Transported

Police

Hearse

Black

Other

P18. Medical

Condition

P17. EMS

AirbagPosition

EMS

Private Vehicle

ActionMotorist-

P16.

Agency Code

Facility Code

Left

Center

Right

No Defects Apparent

Obviously Intoxicated

Unknown

Pushing vehicle

Deployed - Front

Not Deployed

Unknown

Physical Impairment

Deployed - Side

No Airbag

Entering/Crossing Roadway

Approaching/leaving vehicle

Hit and Run

Affected by Exhaust Fumes

Deployed - Both

P19.

Drinking - Not impaired

Using Drugs - Impaired

P20. Non

Walking/running/playing/cycling

Playing/working on vehicle

Alcohol Test Information

Drinking - Impaired

Using Drugs - Not Impaired

Type

None

Serum

Fell Asleep/Fainted/Fatigue

Pending Lab Results

Working

Standing

Blood

Urine

No Apparent Improper Driving

Made Improper Turn

Not Visible (Dark Clothing)

Breath

(3)

Status

Test refused

Test given, pending

Circumstance

Failed to Yield Right of Way

Left of Center

Operating Defective Equipment

None given

Test given

Result

Following Too Closely

Failure to keep proper lane/Run off road

Passed Stop Sign

Speed Too Fast For Conditions

Avoidance

Pedestrian Actions

Contributing

Driving Under The Influence

Drove on Wrong Side of Road

Ran Red Light

Type

Blood

Urine

Faulty Equipment

Illegally Crossing Median

Visibility Obstructed

Drug Test Information

Animal on Roadway

Fatigued/Asleep

Roadway Defects

None

Serum

P21.

Exceeded Lawful Speed

Improper Lane Change

Improper Backing

Status

None given

Test given, pending

Improper Passing/Overtaking

Lying and/or illegally in roadway

See Crash Description

Test refused

Test given

Occupant

O0. Vehicle #:

O1.

First Name

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

O2. Address

O3.

Address

Front-right

Sleeper of Truck Cab

Lap Belt

Same as

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

Person #

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O4.

City

O5.

State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

O8.Sex

O9.Race

O10.Age

ExtricatedO11.

EjectionO12.

InjuryO13.Type

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

White

Hispanic

Not

Partially

Complaint of Pain

Deployed - Side

No Airbag

Black

Other

Totally

Serious

Killed

Deployed - Both

Xport

Not Transported

Police

Hearse

O16. EMS

O17. Medical

O15.

EMS

Private Vehicle

Agency Code

Facility Code

Occupant

O0. Vehicle #:

O1.

First Name

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

O2. Address

O3. Address

Front-right

Sleeper of Truck Cab

Lap Belt

Same as

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

Person #

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O4.

City

O5.

State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

O8.Sex

RaceO9.

O10.Age

ExtricatedO11.

EjectionO12.

InjuryO13.Type

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

White

Hispanic

Not

Partially

Complaint of Pain

Deployed - Side

No Airbag

Black

Other

Totally

Serious

Killed

Deployed - Both

0382395460	Xport	Not Transported	Police	Hearse	O16. EMS	O17. Medical
0382395460	O15.	EMS	Private Vehicle		Agency Code	Facility Code
		EMS	Private Vehicle		Agency Code	Facility Code

V0.

Vehicle #: V1. Total Occupants

Agency Number

Agency Case Number

MUCR

Vehicle

Owner Information

V2. State

V3.

Year

V4.

License Plate Number

Same as V12.

Owner Name

Driver

V5.

Make

V6. Model Year

V13.

Address

V7.

Vehicle Model

V8.

Vehicle Color

V14.

City

V10. Speed Zone V11. Est. Speed

V19. No Proof V17. Insurance Company Name

of Insurance

V9. Damage:

Heavy

Light

None

Collision w/ Person, Vehicle/Non-fixed Object

Non-Collision

Collision w/ Fixed Object

Animal

Cargo Loss/Shift

Attenuator/Cushion

Bicyclist

Crossover

Bridge Structure

EventsofSequence

Maintenance Equip.

Equipment Failure

Culvert

ActionVehicleV21.

Moving Vehicle

Fell/Jump from Vehicle

Curb

Parked Vehicle

Fire/Explosion

Ditch

Pedestrian

Immersion

Embankment

Train

Jackknife

Fence

Slowing Vehicle

Median/Centerline

Guardrail

Stopped Vehicle in Road

Thrown/Falling Object

Mailbox

V20.

Off roadway/Left

Median Barrier

Off roadway/Right

Post/Pole/Support

Overturn/Rollover

Tree

Unit Separation

Other Fixed Object

Over Correcting/Steering

ConfigurationVehicleV22.

Passenger Car

School Bus

Train

ContactInitialV23.

TravelofDirectionV24.

Light Truck

Under

Single-Unit Truck(2)

Truck/Trailer

Stationwagon/Van

Single-Unit Truck(3+)

Emergency Veh.

Overturn

SUV

Farm Tractor

Commercial Bus

None

Motorcycle

Tractor/SemiTrailer

ATV

Other

Tractor(2)

Farm Equip.

Other

Tractor(3)

Unknown Truck

ControlTrafficDevice

Channel-Painted

Officer

Straight/Level

Bridge

2 Lane

Channel-Physical

RR Flashing Signal

RoadV29.Design

CharacterRoad

Intersect two roads

Private Drive

Flag Person

RR Signal and Gate

Curve/Level

Crossover

Flashing Signal Red

Signal

Straight/Grade

Curve/Hillcrest

Parking Lot

V26.

Flashing Signal Yellow

Stop Sign

V28.

No Passing

Railroad Sign

1 Lane

None

Yield Sign

Straight/Hillcrest

Begin/End Divided Road

V30. Divided?

V27. Device Functioning?

Curve/Grade

One-Way

V31. Center Turn Lane?

Page

V15. State		V16. Zip Code

V18. Policy Number

Going Straight

Making Left Turn

Stopped

Slow/Stop in Road

Parked

Backing

Making Right Turn

3 Lane
Frontage/Ramp		Type
Frontage/Ramp
One Way		Surface
One Way
Unpaved		Road
Unpaved		V32.
Yes	No	V32.
Yes	No
Yes	No

Avoidance

Lane Change

Leaving Parking

Overtaking/Passing

Parking Position

Making U Turn

In Tow

	Type	None
	Type	Right only
	Bikeway	Right only
	Bikeway	Both Sides
		Left Only
	V25.	Separate
		Signed

Asphalt

Concrete

Dirt

Gravel

Other - See Narrative

V33. Towed?

Yes

V34. Authority:

Owner

Police

Other

V35. Towed By:

Commercial Vehicle

C1.

Carrier ID Number:

US DOT

State

Mexico

C2. Authority

Canada

C3.

Carrier Name

C4.

Carrier Address

C5. City

C6. State

C7. Zip Code

C8. GVWR #

9614432302

Type	Auto transporter		Flatbed
	Bus<15		Garbage/refuse
Body
	Bus 15+		Grain/chips/gravel

Cargo	Cargo tank		Other
	Concrete Mixer		Pole/log
C9.
	Dump		Van/enclosed box

	None
C10. Commodity Hauled
	C11. Placard ID
C12. HAZMAT Released		Yes	No

MUCR

Additional Occupants

		O0. Vehicle #		O1.	First Name

	O2. Address			O3. Address
	Same as
	Person #

				O4.	City



Sex		M	Race	White		Hispanic
Sex			Race
O8.			O9.
O8.		F	O9.	Black		Other
		F

		O0. Vehicle #		O1.	First Name		O15.Xport
		O0. Vehicle #		O1.	First Name

	O2. Address			O3.	Address
	Same as
	Person #

				O4.	City


Sex		M	Race	White		Hispanic
Sex			Race

O8.		F	O9.	Black		Other
		F


							O15.Xport
		O0. Vehicle #		O1.	First Name

	O2. Address			O3. Address
	Same as
	Person #

				O4.	City


Sex		M	Race	White		Hispanic
				White		Hispanic

O8.		F	O9.	Black		Other
		F


		O0. Vehicle #		O1.	First Name		O15.Xport
		O0. Vehicle #		O1.	First Name
				O3.	Address
	O2. Address			O3.	Address
	Same as
	Person #

				O4.	City



Sex		M	Race	White		Hispanic
Sex			Race

O8.		F	O9.	Black		Other
		F


							Xport
	6895084358						O15.

Agency NumberAgency Case Number

Page

o f

Occupant

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

Front-right

Sleeper of Truck Cab

Lap Belt

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O5. State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

AgeO10.

ExtricatedO11.

EjectionO12.

TypeInjuryO13.

Not

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

Partially

Complaint of Pain

Deployed - Side

No Airbag

Totally

Serious

Killed

Deployed - Both

Not Transported

Police

Hearse

O16. EMS

O17. Medical

EMS

Private Vehicle

Agency Code

Facility Code

Occupant

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

Front-right

Sleeper of Truck Cab

Lap Belt

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O5. State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

AgeO10.

ExtricatedO11.

EjectionO12.

TypeInjuryO13.

Not

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

Partially

Complaint of Pain

Deployed - Side

No Airbag

Totally

Serious

Killed

Deployed - Both

Not Transported

Police

Hearse

O16. EMS

O17. Medical

EMS

Private Vehicle

Agency Code

Facility Code

Occupant

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

Front-right

Sleeper of Truck Cab

Lap Belt

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O5. State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

AgeO10.

ExtricatedO11.

EjectionO12.

TypeInjuryO13.

Not

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

Partially

Complaint of Pain

Deployed - Side

No Airbag

Totally

Serious

Killed

Deployed - Both

Not Transported

Police

Hearse

O16. EMS

O17. Medical

EMS

Private Vehicle

Agency Code

Facility Code

Occupant

Last Name

Front-Driver

3rd-middle

Shoulder and Lap Belt

Front-Middle

3rd-right

(2)

None

PositionO6.

Equip.Safety

Front-right

Sleeper of Truck Cab

Lap Belt

2nd-left

Encl. Pass./Cargo Area

Automated Restraint

2nd-middle

Unencl. Pass./Cargo Area

Shoulder Belt

O5. State

2nd-right

Riding on Exterior

O7.

Child Safety Seat

Unborn Child

3rd-left

Towed Vhcl./Trailer

Helmet

AgeO10.

ExtricatedO11.

EjectionO12.

TypeInjuryO13.

Not

None

Life Threatening

AirbagO14.

Deployed - Front

Not Deployed

Partially

Complaint of Pain

Deployed - Side

No Airbag

Totally

Serious

Killed

Deployed - Both

Not Transported

Police

Hearse

O16. EMS

O17. Medical

EMS

Private Vehicle

Agency Code

Facility Code

Get Mississippi Accident Report File

File Features

Fact Name	Detail
Governing Law	The Mississippi Accident Report form is governed by Mississippi Code § 63-3-409, which mandates the reporting of motor vehicle accidents.
Purpose	This form serves to document the details of motor vehicle accidents, including information about vehicles, injuries, and contributing factors.
Required Information	Key details such as the date and time of the accident, vehicle information, and parties involved must be accurately recorded.
Witness Information	The form includes sections to gather information from witnesses, which can be crucial for understanding the circumstances of the accident.
Submission	Completed forms must be submitted to the appropriate law enforcement agency and are often used in legal proceedings and insurance claims.

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