"Late Accident Report Form" - Guilford, Connecticut

Late Accident Report Form is a legal document that was released by the Police Department - Town of Guilford, Connecticut - a government authority operating within Connecticut. The form may be used strictly within Guilford.

Form Details:

  • Released on October 1, 1999;
  • The latest edition currently provided by the Police Department - Town of Guilford, Connecticut;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Police Department - Town of Guilford, Connecticut.

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Download "Late Accident Report Form" - Guilford, Connecticut

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LATE ACCIDENT REPORT FORM
GUILFORD POLICE DEPARTMENT
400 CHURCH STREET
GUILFORD, CT 06437
DATE OF ACCIDENT
DAY OF WEEK
TIME
#OF VEHICLES
POLICE CASE NUMBER
(MONTH) (DAY) (YEAR)
INVOLVED
/
/
AM
PM
CITY OR TOWN (NAME)
ACCIDENT OCCURRED ON (Street name or route #)
AT INTERSECTION WITH (street name or route #)
IF NOT AT INTERSECTION
1. Give distance and check either
2. Check Direction
3. Give next intersecting street (name or route #)
“feet” or “tenths” of a mile
or location of parking lot.
( ) Feet
N
S
E
W
( ) Tenths
( ) ( ) ( )
( )
of __________________________________________________
OPERATOR AND VEHICLE #1
OPERATOR AND VEHICLE #2
(or just vehicle if parked)
Operator # 1
NAME (last, first, middle initial)
Operator #2
NAME (last, first, middle initial)
ADDRESS (Street, number and name)
ADDRESS(Street, number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
Lic State/ Operator License Number
DATE OF BIRTH
Lic State/Operator License Number
DATE OF BIRTH
/
/
/
/
/
/
VEHICLE #1 OWNER NAME (if same as operator #1, enter, same)
VEHICLE #2 OWNER NAME(if same as operator #2, enter, same
ADDRESS (street number and name)
ADDRESS(street number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE IDENTIFICATION NUMBER(not engine number)
VEHICLE IDENTIFICATION NUMBER(not engine number)
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
VEHICLE #1 TOWED TO (if not towed, indicate “none”)
VEHICLE #2 TOWED TO (if not towed, indicate “none”)
DAMAGE TO
1. Described the property and extent of damage (e.g. 50 feet of fence knocked down)
PROPERTY
_____________________________________________________________________
OTHER THAN
2. Give Name and Address of property owner
INVOLVED
______________________________________________________________________
VEHICLES
AGE
SEX
NAME AND ADDRESS OF WITNESS
AGE
SEX
NAME AND ADDRESS OF WITNESS
INSTRUCTIONS:
1. Fill in ALL known information.
2. Indicate unknown information by using “UNK”
3. If you need assistance confer with your attorney or insurance agent and return completed form to this department.
LATE ACCIDENT REPORT FORM
GUILFORD POLICE DEPARTMENT
400 CHURCH STREET
GUILFORD, CT 06437
DATE OF ACCIDENT
DAY OF WEEK
TIME
#OF VEHICLES
POLICE CASE NUMBER
(MONTH) (DAY) (YEAR)
INVOLVED
/
/
AM
PM
CITY OR TOWN (NAME)
ACCIDENT OCCURRED ON (Street name or route #)
AT INTERSECTION WITH (street name or route #)
IF NOT AT INTERSECTION
1. Give distance and check either
2. Check Direction
3. Give next intersecting street (name or route #)
“feet” or “tenths” of a mile
or location of parking lot.
( ) Feet
N
S
E
W
( ) Tenths
( ) ( ) ( )
( )
of __________________________________________________
OPERATOR AND VEHICLE #1
OPERATOR AND VEHICLE #2
(or just vehicle if parked)
Operator # 1
NAME (last, first, middle initial)
Operator #2
NAME (last, first, middle initial)
ADDRESS (Street, number and name)
ADDRESS(Street, number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
Lic State/ Operator License Number
DATE OF BIRTH
Lic State/Operator License Number
DATE OF BIRTH
/
/
/
/
/
/
VEHICLE #1 OWNER NAME (if same as operator #1, enter, same)
VEHICLE #2 OWNER NAME(if same as operator #2, enter, same
ADDRESS (street number and name)
ADDRESS(street number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE IDENTIFICATION NUMBER(not engine number)
VEHICLE IDENTIFICATION NUMBER(not engine number)
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
VEHICLE #1 TOWED TO (if not towed, indicate “none”)
VEHICLE #2 TOWED TO (if not towed, indicate “none”)
DAMAGE TO
1. Described the property and extent of damage (e.g. 50 feet of fence knocked down)
PROPERTY
_____________________________________________________________________
OTHER THAN
2. Give Name and Address of property owner
INVOLVED
______________________________________________________________________
VEHICLES
AGE
SEX
NAME AND ADDRESS OF WITNESS
AGE
SEX
NAME AND ADDRESS OF WITNESS
INSTRUCTIONS:
1. Fill in ALL known information.
2. Indicate unknown information by using “UNK”
3. If you need assistance confer with your attorney or insurance agent and return completed form to this department.
PLEASE DRAW A DIAGRAM OF WHAT HAPPENED
(be sure to include all vehicle, pedestrian and bicyclist maneuvers both prior and after the collision)
Number of each vehicle as it appears on the front of this report. Indicate the direction each was traveling by an arrow.
Draw an arrow here
Include all objects involved (e.g. buildings, bridges, poles, fences, or guard ports, etc.)
pointing North (
)
DIRECTION OF TRAVEL OF EACH VEHICLE, PEDESTRIAN, ETC.
N
S
E
W
Vehicle #1 going
(
)
(
) (
) (
)
on__________________________________________________________________________________
N
S
E
W
Vehicle #2 going
(
)
(
)
(
) (
)
on___________________________________________________________________________________
NARRATIVE - DESCRIBE EVENTS AS TO HOW COLLISION OCCURRED
(D) WEATHER CONDITIONS (check one)
(E) ROAD SURFACE (check one)
(F) LIGHT CONDITIONS (check one)
1 Clear___
6 Sleet or
1 Dry ____
6
Muddy _____
1
Daylight _____
2 Raining _____
Freezing Rain _____
2 Wet ____
7
Freshly Oiled _____
2
Dawn _____
3 Fog ____
7 Cloudy _____
3 Icy _____
8
Loose Sand _____
3
Dusk _____
4 Rain and Fog____
8 Other (specify)
4 Snowy _____
9 Other(specify)
4
Darkness, no highway illumination_____
5 Snowing ____
________________
5 Slushy _____
___________________
5
Darkness, with highway illumination_____
I declare under penalties provided by law this report has been examined by me and to the best of my knowledge the
information contained herein is true and correct.
PLEASE SIGN HERE_____________________________________________ DATE _________________
W ritten signature of operator submitting this report must be the same as that of Operator #1 on the face of this report.
Signature must be signed in ink.
GPD 30
REV 10/99
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