RV USE ONLY Bibi Sonos Agonoy REPORT OF TRAFFIC ACCIDENT INVOLVING AN AUTONOMOUS VEHICLE. Instructions: Please print within the spaces and boxos on this form. f you need to provide additional information an a separate pleoe of paper(s) or you include @ copy of any law enforcement agency report, please check the box to indicate “Additional Information Attached.” + Welta unk (for unknown) o° none in any space or box when you do not have the information on the other party involved, + Give Ineurance information that Is complete and which correctly and fuly Identifies the company that issued the Ineuranco polley oF suraty bond, or whethar thera isa certificate of seltinsurance, + Placa the National Association of Insurance Commissioners (NAIC) number for your Insurance or Surety Company in the boxes provided. The NAIC number should be looated on the proot of insurance provided by you company or you ean contact Yyour insuror for inat information, + Ident any person involvedin the accident (drlver, passenger, bioycist, padestilan, et) thal you saw was injurecior complained (of bodily Injury or know to be deceased, ‘+ ocord in the PROPERTY DAMAGE line any damage to talephions polos, fences, street signs, guard post, trees, INestork, dogs, buildings, parted vehicles, etc. inclucing a desorption of the damage, + Once you have completed this report, plaase mall to: Department of Motor Vehicles, Occupational Licensing Branch, P.O. Box 982842, MS: L224, Seoramonto, CA 94282-3420 SECTION 1 — MANUFACTURER'S INFORMATION ‘Lexus Google Auto LLC SECTION 2 — ACCIDENT INFORMATION Sra eT ERT rer rae on/ig2016 | Clan GZ pm|2012 Lows RXA50n 1 Camino Real and Castro St Mounatn View Sante Cie cA 08 Vehicle Woving Tiwalvedin — £) Pedestrian ERT NTT wast (Stopped in Tiallc the Accident: 1 Biyalist CI Other | Sere La STORE LAT Tene ea re — Teor RT SRE RET SRT TE SERES ATF RRTEP TET - ~ FRO SECTION 3 — OTHER PARTY'S INFORMATION 2002 Nowityer Lowilvos Aniulned Bus, cies 2300 TREE RATS ——— SRE ONTOS ERR ROR Vehicle [dd Moving Involved in Cl Pedestrian er oa: lp Sloapedin Tattle _the Aveldont: C Boyce! "C1 omar 1 nee RST Go pee oR STE raer Ren Sel road esses cece CD Additional Information attached, eivepe seme I‘SECTION 4 ~ INJURYIDEATH, PROPERTY DAMAGE ‘ae aH an Tae _ CHECK ALL THAT APPLY CJ inured C1 Deceased 1) Driver C1 Passenger I Bieyolist I RRB rr eRe aT are CHECK ALL THAT APPLY [2 Injured C} Deceased C1 Driver) Passenger L) Bieyclist [1 Property sess ———prerea TREES Sr Herre Sa ) ces ara ae RT I) is Sa EE rear ae aa ‘Additional information attached, aac : ‘SECTION 5 — ACCIDENT DETAILS - DESCRIPTION 1 Autonomous Mode Conventional Moda A Google Lexus-model autonomous vehicle ("Google AV") was uaveling in autonomous mode eastbound on Et Canine Real in Mountain ‘View in te for right-hand lane eporouching the Casio St. iniersecion, As the Google AV approsched the intersection it sigualed is nent ‘ommke wright cum on red onto Casto St. ‘The Google AY then moved ro ve right-hand side ofthe lane to pass traffic inthe say las that was stopped a! the intersection und proceeding straight, However, the Google AV had ro carne 10 stop eid go srbund sandbegs positioned !roundl «storm drain that were blockia its put. When the ight tured green, traffic inthe lane continued past the Google AV. Afr a few cuss tad passed. che Google AY begun to proceed back inin the center ofthe Lane to pass the sane bags. A public transit bus was approzehing from betind ‘The Gngle AV teat drives saw the bus approaching in the left side mirzoe but belisved the bus would stop oF slow to allow the Google AV 10 continue. Approximately toe seconds iter, us the Google AV was recaering te center of the lane it ‘mati eantnet wrth the side of the bus. The Google AV vat operating in eutonomous mode und traveling at less than 2 mph, and the bus was travelling at about 15 mph athe time of contact. ‘The Gongle AV suattined body damnage to the lel front fender, the lft rom! whee! aad one cf is drivers-sie sensors, There ware no lnjuries reported at the scene. Additional information attached, SECTION 6 — CERTIFICATION | cortity (or declare) under penalty of perjury under the laers of the State of California that the foregoing te true and correct, Hurther certify that {am the authorizad Administrator of the program for the above named employer. STE ERAT ORES RE ANE ATION OT ree CHRIS oe DIRECTOR x OLE — e