1. REPORT NO. REPUBLIC OF THE PHILIPPINES 2.

PROVINCIAL OFFICE
BMPS-TS-0818-01 PHILIPPINE NATIONAL POLICE Misamis Oriental
3. POLICE STATION TRAFFIC ACCIDENT REPORT FORM 4. REGIONAL OFFICE
BALINGASAG 10
5. NUMBER OF VEHICLES INVOLVED 2 0 9. ACCIDENT SEVERITY 10. Month 11. Day 12. Year
f. Fatal Accident
6. NUMBER OF DRIVER CASUALTIES 0 S. Serious Injury Accident DATE: August 10, 2018
7. NUMBER OF PASSENGER CASUALTIES 0 M. Minor Injury Accident 13. DAY OF WEEK Friday
8. NUMBER OF PEDESTRIAN CASUALTIES 0 0 D. Property Damage Only 14. TIME (Military Time) 1940H
15. JUNCTION TYPE 16. TRAFFIC CONTROL 17. COLLISSION TYPE 18. MOVEMENT

Y
1. None
2. Centerline
1. Not at Junction 5. 1. Head On 6. Hit Object in Road 1. 1-Way
3. Pedestrian Crossing 2. Rear End 7. Hit Object of Road
4. School Crossing 3. Right Angle 8. Hit Parked Vehicle
2. 2-Way
2. 6. 5. Police Controlled 4. Side Swipe 9. Hit Pedestrian
6. Traffic Lights 5. Overturned Vehicle 10. Hit Animal 19. SEPARATION
7. Stop Sign
3. 7. Railway 11. Other ………………… 1. Median
8. Give Way
9. Other …………………… 2. No Median
4. 8. Other

20. WEATHER 21. LIGHT 22. ROAD CHARACTER 23. SURFACE 24. SURFACE 25. MAIN CAUSE 26. ROAD CLASS
1. Fair 1. Straight + Flat CONDITION TYPE
2. Rain 1. Daylight 2. Curve only 1. Vehicle Defect 1. National
3. Win 2. Dawn/Dusk 3. Incline only 1. Dry 1. Concrete 2. Road Defect 2. Provincial
4. Smoke 3. Night (lit) 4. Curve + Incline 2. Wet 2. Asphalt 3. Human Error 3. City
5. Fog 4. Night (unlit) 5. Bridge…………………… 3. Muddy 3. Gravel 4. Other 4. Municipal
6. Dazzle 6. Crest 4. Flooded 4. Earth 5. Barangay
7. Storm 5. Other
27. ROAD REPAIRS 28. HIT & RUN 29. LOCATION TYPE
1. Yes 1. Yes 1. Urban Area
2. No 2. No 2. Rural Area
LOCATION
Distance…………………..…………. (km/m)
PUROK 6 BRGY. , BALINGASAG, MIS. OR.
Name of City/Town/Barangay ………………………………………………………………………………………………………………………………….
Landmark 1 ...………………………………….. Distance…………………..…………. (km/m)
NATIONAL HIGH WAY
Name of Road…………………………………………………………… Between
Landmark 2 ……………………………………… Distance…………………..…………. (km/m)
JUNCTION ACCIDENT ONLY Name of SECOND Road Distance…………………..………….
……………………………………………………………………………………………. (km/m)
LOCATION Show site in relation to prominent landmarks such as KM posts or Collision diagram Mark the position and direction of each vehicle and details of the road
SKETCH Major Intersections. Mark Distances to the landmarks. SKETCH Layout at the site of the accident.
MAP

(MC RACAL) TO GINGOOG

V1 BRGY. TALUSAN, BALINGASAG MIS. OR

V2
(UV VAN)
TO CAGAYAN DE ORO

Signatures: Driver 1………………………………….. Driver 2 ………………………………

POLICE DESCRIPTION OF ACCIDENT WITNESSES
1. Name
. ON AUGUST 10, 2018 AT ABOUT 7:40 PM, TRAFFIC ACCIDENT TRANSPIRED …………………………………………….……………………………………
ALONG NATIONAL HIGHWAY, BRGY. TALUSAN, BALINGASAG, MISAMIS ORIENTAL Address
WHEREIN A UTILITY VAN V2 (DRIVEN BY GERRY VIDAL) HEADING TOWARDS BUTUAN …………………………………….…………………………………………….
CITY WITH ITS PASSENGERS WHO ATTEMPTED TO OVERTOOK THE AMBULANCE AND 2. Name
MOTORELA ANS UPON REACHING THE IMPACT SITE IT ACCIDENTALLY COLLIDED TO A …………………………………….……………………………………………
SINGLE MOTORCYCLE V1 (DRIVEN BY JEANY DANDOY) COMING FROM THE OPPOSITE Address
LANE WHICH CAUSES TO A SERIOUS PHYSICAL INJURY OF THE V1 DRIVER AND THE …………………………………….…………………………………………….
BACK RIDER AND A SEVERE DAMAGE OF SAID MOTORCYCLE AND ALSO INCURRED OF INVESTIGATING OFFICER
SAID V2 AND MINOR INJURIES OF SAME OF ITS PASSERGER.
SAID INJURED PERSONS WERE IMMEDIATELY BROUGHT TO Name/Rank : PO3 Elpedio Q Boniao Jr.
MOPH-BALINGASAG WHILE V1 DRIVER AND BACK RIDER WERE BROUGHT TO NMMC Date …08/14/2018
FOR FURTHER TREATMENT. BOTH VEHICLES INCURRED DAMAGE WHICH ONLY
SUPERVISING OFFICER
COMPETENT SHOP MECHANIC COULD ASCERTAIN THE COST OF REPAIR.
Name/Rank : PSI ISMAEL VIRGIL OTOC
GUNDAYA
Date …08/14/2018
DRIVER STATEMENTS ACTION TAKEN
Driver 1 INVESTIGATED
……………………………………………………………………………………………………………………… RECOMMENDATION
……………………………………………………………………………………………………………………… FOR INSURANCE PURPOSES
Driver 2 STATUS OF CASE
……………………………………………………………………………………………………………………… SETTLED
………………………………………………………………………………………………………………………
ORIGINAL
 Additional form(s) will be needed if there are more than 2 vehicles, more than 4 passenger casualties or more than 2 pedestrian casualties.
Fill in the report no., provincial office, police station and dates and fix forms together securely.
1. REP. NO 2. PROV OFFICE 3. POL STN 4. REG OFFICE 5. DATE
MIS. OR. BALINGASAG MPS R-10 14/08/2018
30. VEHICLE PLATE NUMBER Name
VEHICLE 1 DRIVER 1
JEANY GALVAN DANDOY
31. OWNER’S NAME ADDRESS
ALOHA M HORTILONA BRGY. BLANCO, BALINGASAG, MISAMIS ORIENTAL
CHASIS NUMBER 32. ENGINE NUMBER LICENSE NUMBER
RMC100CEBU00023766

33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE

OR NO. 1186339980/CR NO. 273150091
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
RACAL 100-30 2015 Female 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE Hospital: NMMC CDOC
1. Bicycle 7. Bus 1. Left Turn 7. Overtaking 13. Parked on Road 16
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
……………..... 4. Too fast 9. Using Cell Phone
5. Too Close 10. Other

36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE
1. Legal 1. North 1. None 5. Tires 1. None 5. Left 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple Drugs Suspected 2. Not Worn
4. West 4. Steering 4. Right 8. Other 2. Not Suspected 3. Not Worn Correctly
………………………

30. VEHICLE PLATE NUMBER Name

VEHICLE 2 ABB7551 DRIVER 2 GERRY DELA CERNA VIDAL
31. OWNER’S NAME JUANALITA P CABANO ADDRESS
WESTERN KOLAMBOG LAPASAN CAGAYAN DE ORO CITY
CHASIS NUMBER 32. ENGINE NUMBER LICENSE NUMBER
JTFJS02P600042933 2KDA566964 K0200082140
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
CR NO. 199553535/ OR NO. 555881266 PDL RC 2 03/05/2023
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
TOYOTA HIACE COMMUTER/2014 MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE
1. Bicycle 7. Bus 1. Left Turn 7.Overtaking 13. Parked on Road Hospital:
49
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
……………..... 4. Too fast 9. Using Cell Phone
5. Too Close 10. Other

36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… ……………………… 2. Not Suspected 3. Not Worn Correctly

PASSENGER CASUALTIES Complete FULL line for each passenger casualty See Reference boxes below
NAME & ADDRESS 46. 47. 48. 49. 50. 51.
VEH NO SEX AGE INJURY/HOSP POSITION ACTION

PEDESTRIAN CASUALTIES Complete FULL line for each pedestrian casualty See Reference boxes below
NAME & ADDRESS 52. 53. 54. 55. 56.
SEX AGE INJURY/HOSP POSITION ACTION

49. PASSENGER INJURY 50. PASSENGER POSITION 51. PASSENGER ACTION 55. PEDESTRIAN LOCATION 56. PEDESTRIAN ACTION
FOR 54. PEDESTRIAN INJURY 1. Front Seat 1. None 1. On Pedestrian Crossing 1. None
REFERENCE F- Fatal 2. Rear Seat 2. Boarding 2. Within 50m Ped 2. Crossing Road
ONLY S- Serious 3. M/Cycle Passenger 3. Alighting Crossing 3. walking Along Road
DO NOT M- Minor 4. Bus Passenger 4. Falling 3. On Central Refuge 4. Walking Along Edge
CIRCLE 5. Outside Sitting 5. Other 4. In Road Centre 5. Playing on Road
6. Outside Standing 5. On footpath/Verge 6. On Footpath
ORIGINAL
1. REPORT NO. REPUBLIC OF THE PHILIPPINES 2. PROVINCIAL OFFICE
BMPS-TS-0818-02 PHILIPPINE NATIONAL POLICE Misamis Oriental
3. POLICE STATION TRAFFIC ACCIDENT REPORT FORM 4. REGIONAL OFFICE
BALINGASAG 10
5. NUMBER OF VEHICLES INVOLVED 1 0 9. ACCIDENT SEVERITY 10. Month 11. Day 12. Year
f. Fatal Accident
6. NUMBER OF DRIVER CASUALTIES 0 S. Serious Injury Accident DATE: August 12, 2018
7. NUMBER OF PASSENGER CASUALTIES 0 M. Minor Injury Accident 13. DAY OF WEEK Sunday
8. NUMBER OF PEDESTRIAN CASUALTIES 0 D. Property Damage Only 14. TIME (Military Time) 1640H
15. JUNCTION TYPE 16. TRAFFIC CONTROL 17. COLLISSION TYPE 18. MOVEMENT

Y
1. None
2. Center line
1. Not at Junction 5. 1. Head On 6. Hit Object in Road 1. 1-Way
3. Pedestrian Crossing 2. Rear End 7. Hit Object of Road
4. School Crossing 3. Right Angle 8. Hit Parked Vehicle
2. 2-Way
2. 6. 5. Police Controlled 4. Side Swipe 9. Hit Pedestrian
6. Traffic Lights 5. Overturned Vehicle 10. Hit Animal 19. SEPARATION
7. Stop Sign
3. 7. Railway 11. Other ………………… 1. Median
8. Give Way
9. Other …………………… 2. No Median
4. 8. Other

20. WEATHER 21. LIGHT 22. ROAD CHARACTER 23. SURFACE 24. SURFACE 25. MAIN CAUSE 26. ROAD CLASS
1. Fair 1. Straight + Flat CONDITION TYPE
2. Rain 1. Daylight 2. Curve only 1. Vehicle Defect 1. National
3. Win 2. Dawn/Dusk 3. Incline only 1. Dry 1. Concrete 2. Road Defect 2. Provincial
4. Smoke 3. Night (lit) 4. Curve + Incline 2. Wet 2. Asphalt 3. Human Error 3. City
5. Fog 4. Night (unlit) 5. Bridge 3. Muddy 3. Gravel 4. Other 4. Municipal
6. Dazzle 6. Crest 4. Flooded 4. Earth 5. Barangay
7. Storm 5. Other
27. ROAD REPAIRS 28. HIT & RUN 29. LOCATION TYPE
1. Yes 1. Yes 1. Urban Area
2. No 2. No 2. Rural Area
LOCATION
Distance…………………..…………. (km/m)
BRGY. HERMANO, BALINGASAG, MIS. OR.
Name of City/Town/Barangay ………………………………………………………………………………………………………………………………….
Landmark 1 ...………………………………….. Distance…………………..…………. (km/m)
NATIONAL HIGH WAY
Name of Road…………………………………………………………… Between
Landmark 2 ……………………………………… Distance…………………..…………. (km/m)
JUNCTION ACCIDENT ONLY Name of SECOND Road Distance…………………..………….
……………………………………………………………………………………………. (km/m)
LOCATION Show site in relation to prominent landmarks such as KM posts or Collision diagram Mark the position and direction of each vehicle and details of the road
SKETCH Major Intersections. Mark Distances to the landmarks. SKETCH Layout at the site of the accident.
MAP

TO GINGOOG
PEDESTRIAN BRGY. HERMANO, BALINGASAG MIS. OR

TOYOTA INNOVA

TO CAGAYAN DE ORO

Signatures: Driver 1………………………………….. Driver 2 ………………………………

POLICE DESCRIPTION OF ACCIDENT WITNESSES
1. Name
ON AUGUST 12, 2018 AT ABOUT 4:40 PM, TRAFFIC ACCIDENT …………………………………………….……………………………………
TRANSPIRED ALONG NATIONAL HIGHWAY AT PUROK 6 BRGY. HERMANO, Address
BALINGASAG, MISAMIS ORIENTAL WHEREIN A TOYOTA INNOVA DRIVEN BY JOHN LEO …………………………………….…………………………………………….
ROA WAS TRAVELING FROM CAGAYAN DE ORO CITY AND WAS HEADING TOWARDS 2. Name
GINGOOG CITY UPON REACHING THE AFOREMENTIONED PLACE A PEDESTRIAN …………………………………….……………………………………………
FEDERICO ALO WAS SUDDENLY CROSS THE NATIONAL HIGHWAY AND WAS Address
ACCIDENTALY BUMPED/HIT AND STUMBLED. THAT DUE TO THE SAID INCIDENT …………………………………….…………………………………………….
FEDERICO SUSTAINED INJURIES ON DIFFERENT PARTS OF HIS BODY AND WAS INVESTIGATING OFFICER
IMMEDIATELY BROUGHT TO MOPH-BALINGASAG FOR MEDICAL ATTENTION AND
THEREAFTER WAS REFERRED TO NMMC FOR FURTHER TREATMENT. THAT THE SAID Name/Rank : PO3 Elpedio Q Boniao Jr.
VEHICLE INCURRED DAMAGES WHICH ONLY A COMPETENT SHOP MECHANIC CAN Date …08/14/2018
ASCERTAIN THE ACTUAL COST OF THE REPAIR.
SUPERVISING OFFICER
.
Name/Rank : PSI ISMAEL VIRGIL OTOC
GUNDAYA
Date …08/14/2018
DRIVER STATEMENTS ACTION TAKEN
Driver 1 INVESTIGATED
……………………………………………………………………………………………………………………… RECOMMENDATION
……………………………………………………………………………………………………………………… FOR INSURANCE PURPOSES
Driver 2 STATUS OF CASE
……………………………………………………………………………………………………………………… SETTLED
………………………………………………………………………………………………………………………
ORIGINAL
 Additional form(s) will be needed if there are more than 2 vehicles, more than 4 passenger casualties or more than 2 pedestrian casualties.
Fill in the report no., provincial office, police station and dates and fix forms together securely.
1. REP. NO 2. PROV OFFICE 3. POL STN 4. REG OFFICE 5. DATE
MIS. OR. BALINGASAG MPS R-10 14/08/2018
30. VEHICLE PLATE NUMBER Name
VEHICLE 1 DRIVER 1
WPO152 JOHN LEO GA ROA
31. OWNER’S NAME ADDRESS
DAE JONG KIM BRGY. POBLACION 2, BALINGASAG, MISAMIS ORIENTAL
CHASIS NUMBER 33. ENGINE NUMBER LICENSE NUMBER
KUN405094373 2KDU289693 KO2-15-010988
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
OR NO. 10898511910 /CR NO. 180498846 PDL RC 1,2,3 02/12/2023
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
TOYOTA INNOVA2.5J/2013 MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE Hospital: NMMC CDOC
1. Bicycle 7. Bus 1. Left Turn 7. Overtaking 13. Parked on Road 32
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
WAGON 4. Too fast 9. Using Cell Phone
5. Too Close 10. Other

36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… 2. Not Suspected 3. Not Worn Correctly

30. VEHICLE PLATE NUMBER Name

VEHICLE 2 DRIVER 2

31. OWNER’S NAME ADDRESS

CHASIS NUMBER 32. ENGINE NUMBER LICENSE NUMBER

33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE

MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY

1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE
1. Bicycle 7. Bus 1. Left Turn 7.Overtaking 13. Parked on Road Hospital:
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
……………..... 4. Too fast 9. Using Cell Phone
36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE 5. Too Close 10. Other
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… ……………………… 2. Not Suspected 3. Not Worn Correctly

PASSENGER CASUALTIES Complete FULL line for each passenger casualty See Reference boxes below
NAME & ADDRESS 46. 47. 48. 49. 50. 51.
VEH NO SEX AGE INJURY/HOSP POSITION ACTION

PEDESTRIAN CASUALTIES Complete FULL line for each pedestrian casualty See Reference boxes below
NAME & ADDRESS 52. 53. 54. 55. 56.
SEX AGE INJURY/HOSP POSITION ACTION

49. PASSENGER INJURY 50. PASSENGER POSITION 51. PASSENGER ACTION 55. PEDESTRIAN LOCATION 56. PEDESTRIAN ACTION
FOR 54. PEDESTRIAN INJURY 1. Front Seat 1. None 1. On Pedestrian Crossing 1. None
REFERENCE F- Fatal 2. Rear Seat 2. Boarding 2. Within 50m Ped 2. Crossing Road
ONLY S- Serious 3. M/Cycle Passenger 3. Alighting Crossing 3. walking Along Road
DO NOT M- Minor 4. Bus Passenger 4. Falling 3. On Central Refuge 4. Walking Along Edge
CIRCLE 5. Outside Sitting 5. Other 4. In Road Centre 5. Playing on Road
6. Outside Standing 5. On footpath/Verge 6. On Footpath
ORIGINAL
1. REPORT NO. REPUBLIC OF THE PHILIPPINES 2. PROVINCIAL OFFICE
BMPS-TS-0818-04 PHILIPPINE NATIONAL POLICE Misamis Oriental
3. POLICE STATION TRAFFIC ACCIDENT REPORT FORM 4. REGIONAL OFFICE
BALINGASAG 10
5. NUMBER OF VEHICLES INVOLVED 2 0 9. ACCIDENT SEVERITY 10. Month 11. Day 12. Year
f. Fatal Accident
6. NUMBER OF DRIVER CASUALTIES 0 S. Serious Injury Accident DATE: September 01, 2018
7. NUMBER OF PASSENGER CASUALTIES 0 M. Minor Injury Accident 13. DAY OF WEEK Saturday
8. NUMBER OF PEDESTRIAN CASUALTIES 0 D. Property Damage Only 14. TIME (Military Time) 1630H
15. JUNCTION TYPE 16. TRAFFIC CONTROL 17. COLLISSION TYPE 18. MOVEMENT

Y
1. None
2. Center line
1. Not at Junction 5. 1. Head On 6. Hit Object in Road 1. 1-Way
3. Pedestrian Crossing 2. Rear End 7. Hit Object of Road
4. School Crossing 3. Right Angle 8. Hit Parked Vehicle
2. 2-Way
2. 6. 5. Police Controlled 4. Side Swipe 9. Hit Pedestrian
6. Traffic Lights 5. Overturned Vehicle 10. Hit Animal 19. SEPARATION
7. Stop Sign
3. 7. Railway 11. Other ………………… 1. Median
8. Give Way
9. Other …………………… 2. No Median
4. 8. Other

20. WEATHER 21. LIGHT 22. ROAD CHARACTER 23. SURFACE 24. SURFACE 25. MAIN CAUSE 26. ROAD CLASS
1. Fair 1. Straight + Flat CONDITION TYPE
2. Rain 1. Daylight 2. Curve only 1. Vehicle Defect 1. National
3. Win 2. Dawn/Dusk 3. Incline only 1. Dry 1. Concrete 2. Road Defect 2. Provincial
4. Smoke 3. Night (lit) 4. Curve + Incline 2. Wet 2. Asphalt 3. Human Error 3. City
5. Fog 4. Night (unlit) 5. Bridge 3. Muddy 3. Gravel 4. Other 4. Municipal
6. Dazzle 6. Crest 4. Flooded 4. Earth 5. Barangay
7. Storm 5. Other
27. ROAD REPAIRS 28. HIT & RUN 29. LOCATION TYPE
1. Yes 1. Yes 1. Urban Area
2. No 2. No 2. Rural Area
LOCATION
Distance…………………..…………. (km/m)
BRGY. NAPALIRAN, BALINGASAG, MIS. OR.
Name of City/Town/Barangay ………………………………………………………………………………………………………………………………….
Landmark 1 ...………………………………….. Distance…………………..…………. (km/m)
Name of Road…………………………………………………………… Between
Landmark 2 ……………………………………… Distance…………………..…………. (km/m)
JUNCTION ACCIDENT ONLY Name of SECOND Road ……………………………………………………………………………………………. Distance…………………..………….
(km/m)
LOCATION Show site in relation to prominent landmarks such as KM posts or Collision diagram Mark the position and direction of each vehicle and details of the road
SKETCH Major Intersections. Mark Distances to the landmarks. SKETCH Layout at the site of the accident.
MAP

MOUNTAIN SIDE

TO GINGOOG TO CDO CITY

POINT OF IMPACT

SITE: SITIO PUNTAGURDA BRGY. HERMANO, BALINGASAG MISAMIS

ORIENTAL

Signatures: Driver 1………………………………….. Driver 2 ………………………………

POLICE DESCRIPTION OF ACCIDENT WITNESSES
1. Name
ON SEPTEMBER 01, 2018 AT ABOUT 4:30 PM, MOTOR VEHICLE …………………………………………….……………………………………
NON-TRAFFIC ACCIDENT TRANSPIRED AT PRIVATE DRIVEWAY OF NAPALIRAN GRAVEL Address
DEN CRUSHER, BRGY. NAPALIRAN, BALINGASAG, MISAMIS ORIENTAL WHEREIN A …………………………………….…………………………………………….
V1(DUMP TRUCK) DRIVEN BY EDILBERTO VALLEDOR WHILE LOADING A ¾ CRUSHED 2. Name
GRAVEL SUDDENLY A MECHANICAL FAILURE HAPPENED THE MAXI BRAKE SYSTEM …………………………………….……………………………………………
WAS LOOSED, THUS V1 MOVING FORWARD ON ITS OWN AND WAS ACCIDENTALLY Address
COLLIDED INTO THE REAR PORTION OF ANOTHER V2(DUMP TRUCK) DRIVEN BY …………………………………….…………………………………………….
ARMANDO DAGAAS. THAT DUE TO THE SAID IMPACT THE V1 INCURRED DAMAGES AT INVESTIGATING OFFICER
THE HOOD COVER, FOOT BRAKE AND CLUTCH MASTER HOLDER, WIND SHIELD
CRACKED AND THE DRIVER DOORSIDE WAS DISALIGNED WHICH ONLY A COMPETENT Name/Rank : PO3 Elpedio Q Boniao Jr.
SHOP MECHANIC CAN ASCERTAIN THE ACTUAL COST OF THE REPAIR. Date …10/03/2018
.
SUPERVISING OFFICER

Name/Rank : PSI ROBERTO SOMODIO CAMBI

Date …10/03/2018
DRIVER STATEMENTS ACTION TAKEN
Driver 1 INVESTIGATED
……………………………………………………………………………………………………………………… RECOMMENDATION
……………………………………………………………………………………………………………………… FOR INSURANCE PURPOSES
Driver 2 STATUS OF CASE
……………………………………………………………………………………………………………………… SETTLED
………………………………………………………………………………………………………………………
ORIGINAL
 Additional form(s) will be needed if there are more than 2 vehicles, more than 4 passenger casualties or more than 2 pedestrian casualties.
Fill in the report no., provincial office, police station and dates and fix forms together securely.
1. REP. NO 2. PROV OFFICE 3. POL STN 4. REG OFFICE 5. DATE
MIS. OR. BALINGASAG MPS R-10 03/09/2018
31. VEHICLE PLATE NUMBER Name
VEHICLE 1 DRIVER 1
130102 EDILBERTO B. VALLEDOR
31. OWNER’S NAME ADDRESS
GLOBAL EASY BUILDER PUROK 6A BAAN RIVERSIDE, BUTUAN CITY
CHASIS NUMBER 34. ENGINE NUMBER LICENSE NUMBER
LZZSCXBCSGN137790 WD61547160707017787 KO1-01-045044
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
OR NO. 261012146 /CR NO. 1090065384 PDL RC 1,2,3,8 22/08/2019
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
HOWO SINOTRUCK MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE Hospital:
1. Bicycle 7. Bus 1. Left Turn 7. Overtaking 13. Parked on Road 48
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
WAGON 4. Too fast 9. Using Cell Phone
5. Too Close 10. Other

36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… 2. Not Suspected 3. Not Worn Correctly

30. VEHICLE PLATE NUMBER Name

VEHICLE 2 130107 DRIVER 2 ARMANDO DAGAAS
31. OWNER’S NAME GLOBAL EASY BUILDER ADDRESS
ONG YIN BUTUAN CITY
CHASIS NUMBER 32. ENGINE NUMBER LICENSE NUMBER
L225DXS03HN208145 WD61542170307058067 KO1-84-002545
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
OR NO. 288265176/CR NO. PDL RC 1,2,3,8 14/07/2023
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
HOWO SINOTRUCK MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE
1. Bicycle 7. Bus 1. Left Turn 7.Overtaking 13. Parked on Road Hospital:
58
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
……………..... 4. Too fast 9. Using Cell Phone
36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE 5. Too Close 10. Other
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… ……………………… 2. Not Suspected 3. Not Worn Correctly

PASSENGER CASUALTIES Complete FULL line for each passenger casualty See Reference boxes below
NAME & ADDRESS 46. 47. 48. 49. 50. 51.
VEH NO SEX AGE INJURY/HOSP POSITION ACTION

PEDESTRIAN CASUALTIES Complete FULL line for each pedestrian casualty See Reference boxes below
NAME & ADDRESS 52. 53. 54. 55. 56.
SEX AGE INJURY/HOSP POSITION ACTION

49. PASSENGER INJURY 50. PASSENGER POSITION 51. PASSENGER ACTION 55. PEDESTRIAN LOCATION 56. PEDESTRIAN ACTION
FOR 54. PEDESTRIAN INJURY 1. Front Seat 1. None 1. On Pedestrian Crossing 1. None
REFERENCE F- Fatal 2. Rear Seat 2. Boarding 2. Within 50m Ped 2. Crossing Road
ONLY S- Serious 3. M/Cycle Passenger 3. Alighting Crossing 3. walking Along Road
DO NOT M- Minor 4. Bus Passenger 4. Falling 3. On Central Refuge 4. Walking Along Edge
CIRCLE 5. Outside Sitting 5. Other 4. In Road Centre 5. Playing on Road
6. Outside Standing 5. On footpath/Verge 6. On Footpath
ORIGINAL
1. REPORT NO. REPUBLIC OF THE PHILIPPINES 2. PROVINCIAL OFFICE
BMPS-TS-0818-04 PHILIPPINE NATIONAL POLICE Misamis Oriental
3. POLICE STATION TRAFFIC ACCIDENT REPORT FORM 4. REGIONAL OFFICE
BALINGASAG 10
5. NUMBER OF VEHICLES INVOLVED 1 0 9. ACCIDENT SEVERITY 10. Month 11. Day 12. Year
f. Fatal Accident
6. NUMBER OF DRIVER CASUALTIES 0 S. Serious Injury Accident DATE: September 01, 2018
7. NUMBER OF PASSENGER CASUALTIES 0 M. Minor Injury Accident 13. DAY OF WEEK Saturday
8. NUMBER OF PEDESTRIAN CASUALTIES 0 D. Property Damage Only 14. TIME (Military Time) 1630H
15. JUNCTION TYPE 16. TRAFFIC CONTROL 17. COLLISSION TYPE 18. MOVEMENT

Y
1. None
2. Center line
1. Not at Junction 5. 1. Head On 6. Hit Object in Road 1. 1-Way
3. Pedestrian Crossing 2. Rear End 7. Hit Object of Road
4. School Crossing 3. Right Angle 8. Hit Parked Vehicle
2. 2-Way
2. 6. 5. Police Controlled 4. Side Swipe 9. Hit Pedestrian
6. Traffic Lights 5. Overturned Vehicle 10. Hit Animal 19. SEPARATION
7. Stop Sign
3. 7. Railway 11. Other ………………… 1. Median
8. Give Way
9. Other …………………… 2. No Median
4. 8. Other

20. WEATHER 21. LIGHT 22. ROAD CHARACTER 23. SURFACE 24. SURFACE 25. MAIN CAUSE 26. ROAD CLASS
1. Fair 1. Straight + Flat CONDITION TYPE
2. Rain 1. Daylight 2. Curve only 1. Vehicle Defect 1. National
3. Win 2. Dawn/Dusk 3. Incline only 1. Dry 1. Concrete 2. Road Defect 2. Provincial
4. Smoke 3. Night (lit) 4. Curve + Incline 2. Wet 2. Asphalt 3. Human Error 3. City
5. Fog 4. Night (unlit) 5. Bridge 3. Muddy 3. Gravel 4. Other 4. Municipal
6. Dazzle 6. Crest 4. Flooded 4. Earth 5. Barangay
7. Storm 5. Other
27. ROAD REPAIRS 28. HIT & RUN 29. LOCATION TYPE
1. Yes 1. Yes 1. Urban Area
2. No 2. No 2. Rural Area
LOCATION
Distance…………………..…………. (km/m)
BRGY. NAPALIRAN, BALINGASAG, MIS. OR.
Name of City/Town/Barangay ………………………………………………………………………………………………………………………………….
Landmark 1 ...………………………………….. Distance…………………..…………. (km/m)
Name of Road…………………………………………………………… Between
Landmark 2 ……………………………………… Distance…………………..…………. (km/m)
JUNCTION ACCIDENT ONLY Name of SECOND Road ……………………………………………………………………………………………. Distance…………………..………….
(km/m)
LOCATION Show site in relation to prominent landmarks such as KM posts or Collision diagram Mark the position and direction of each vehicle and details of the road
SKETCH Major Intersections. Mark Distances to the landmarks. SKETCH Layout at the site of the accident.
MAP

(V2) (V1)

……………

…………….

POINT OF IMPACT

SITE: NAPALIRAN GRAVEL DEN CRUSHER, BRGY. NAPALIRAN BALINGASAG MISAMIS

ORIENTAL

Signatures: Driver 1………………………………….. Driver 2 ………………………………

POLICE DESCRIPTION OF ACCIDENT WITNESSES
1. Name
ON SEPTEMBER 01, 2018 AT ABOUT 4:30 PM, MOTOR VEHICLE …………………………………………….……………………………………
NON-TRAFFIC ACCIDENT TRANSPIRED AT PRIVATE DRIVEWAY OF NAPALIRAN GRAVEL Address
DEN CRUSHER, BRGY. NAPALIRAN, BALINGASAG, MISAMIS ORIENTAL WHEREIN A …………………………………….…………………………………………….
V1(DUMP TRUCK) DRIVEN BY EDILBERTO VALLEDOR WHILE LOADING A ¾ CRUSHED 2. Name
GRAVEL SUDDENLY A MECHANICAL FAILURE HAPPENED THE MAXI BRAKE SYSTEM …………………………………….……………………………………………
WAS LOOSED, THUS V1 MOVING FORWARD ON ITS OWN AND WAS ACCIDENTALLY Address
COLLIDED INTO THE REAR PORTION OF ANOTHER V2(DUMP TRUCK) DRIVEN BY …………………………………….…………………………………………….
ARMANDO DAGAAS. THAT DUE TO THE SAID IMPACT THE V1 INCURRED DAMAGES AT INVESTIGATING OFFICER
THE HOOD COVER, FOOT BRAKE AND CLUTCH MASTER HOLDER, WIND SHIELD
CRACKED AND THE DRIVER DOORSIDE WAS DISALIGNED WHICH ONLY A COMPETENT Name/Rank : PO3 Elpedio Q Boniao Jr.
SHOP MECHANIC CAN ASCERTAIN THE ACTUAL COST OF THE REPAIR. Date …09/04/2018
.
SUPERVISING OFFICER

Name/Rank : PSI ROBERTO SOMODIO CAMBI

Date …09/04/2018
DRIVER STATEMENTS ACTION TAKEN
Driver 1 INVESTIGATED
……………………………………………………………………………………………………………………… RECOMMENDATION
……………………………………………………………………………………………………………………… FOR INSURANCE PURPOSES
Driver 2 STATUS OF CASE
……………………………………………………………………………………………………………………… SETTLED
………………………………………………………………………………………………………………………
ORIGINAL
 Additional form(s) will be needed if there are more than 2 vehicles, more than 4 passenger casualties or more than 2 pedestrian casualties.
Fill in the report no., provincial office, police station and dates and fix forms together securely.
1. REP. NO 2. PROV OFFICE 3. POL STN 4. REG OFFICE 5. DATE
MIS. OR. BALINGASAG MPS R-10 03/09/2018
32. VEHICLE PLATE NUMBER Name
VEHICLE 1 DRIVER 1
130102 EDILBERTO B. VALLEDOR
31. OWNER’S NAME ADDRESS
GLOBAL EASY BUILDER PUROK 6A BAAN RIVERSIDE, BUTUAN CITY
CHASIS NUMBER 35. ENGINE NUMBER LICENSE NUMBER
LZZSCXBCSGN137790 WD61547160707017787 KO1-01-045044
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
OR NO. 261012146 /CR NO. 1090065384 PDL RC 1,2,3,8 22/08/2019
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
HOWO SINOTRUCK MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE Hospital:
1. Bicycle 7. Bus 1. Left Turn 7. Overtaking 13. Parked on Road 48
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
WAGON 4. Too fast 9. Using Cell Phone
5. Too Close 10. Other

36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… 2. Not Suspected 3. Not Worn Correctly

30. VEHICLE PLATE NUMBER Name

VEHICLE 2 130107 DRIVER 2 ARMANDO DAGAAS
31. OWNER’S NAME GLOBAL EASY BUILDER ADDRESS
ONG YIN BUTUAN CITY
CHASIS NUMBER 32. ENGINE NUMBER LICENSE NUMBER
L225DXS03HN208145 WD61542170307058067 KO1-84-002545
33. INSURANCE OR/CR DETAILS LICENSE TYPE EXPIRY DATE
OR NO. 288265176/CR NO. PDL RC 1,2,3,8 14/07/2023
MANUFACTURER (MAKE) MODEL/YEAR 40. DRIVER SEX 42. DRIVER INJURY
HOWO SINOTRUCK MALE 1. Fatal 3. Minor
2. Serious 4. Not Injured
34. VEHICLE TYPE 35. VEHICLE MANEUVER 41. DRIVER AGE
1. Bicycle 7. Bus 1. Left Turn 7.Overtaking 13. Parked on Road Hospital:
58
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead 14. Other
3. Motor cycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 43. DRIVER ERROR
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 1. None 6. No Signal
5. Car 11. Animal 5. Merging 11. Sudden Stop 2. Fatigued/Asleep 7. Bad Overtaking
6. Jeepney 12 Other 6. Diverging 12Parked Off Road 3. Inattentive 8. Bad Turning
……………..... 4. Too fast 9. Using Cell Phone
36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE 5. Too Close 10. Other
1. Legal 1. North 1. None 5. Tires 1. None 5. Left
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Roof 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Multiple 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
4. West 4. Steering 4. Right 8. Other Drugs Suspected 2. Not Worn
……………………… ……………………… 2. Not Suspected 3. Not Worn Correctly

PASSENGER CASUALTIES Complete FULL line for each passenger casualty See Reference boxes below
NAME & ADDRESS 46. 47. 48. 49. 50. 51.
VEH NO SEX AGE INJURY/HOSP POSITION ACTION

PEDESTRIAN CASUALTIES Complete FULL line for each pedestrian casualty See Reference boxes below
NAME & ADDRESS 52. 53. 54. 55. 56.
SEX AGE INJURY/HOSP POSITION ACTION

49. PASSENGER INJURY 50. PASSENGER POSITION 51. PASSENGER ACTION 55. PEDESTRIAN LOCATION 56. PEDESTRIAN ACTION
FOR 54. PEDESTRIAN INJURY 1. Front Seat 1. None 1. On Pedestrian Crossing 1. None
REFERENCE F- Fatal 2. Rear Seat 2. Boarding 2. Within 50m Ped 2. Crossing Road
ONLY S- Serious 3. M/Cycle Passenger 3. Alighting Crossing 3. walking Along Road
DO NOT M- Minor 4. Bus Passenger 4. Falling 3. On Central Refuge 4. Walking Along Edge
CIRCLE 5. Outside Sitting 5. Other 4. In Road Centre 5. Playing on Road
6. Outside Standing 5. On footpath/Verge 6. On Footpath
ORIGINAL