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HomeMy WebLinkAboutApplication Files_82693_pg0248 1 a 09 CONNECTICUT UNIFORM POLICE ACCIDENT REPORT FORM PR-1 REV.01101 GPS READINGS Lattitude: ,"',' A 1 r .� Longitude: ,��.`; a 1 Time: FOR DOT USE ONLY DATE OF ACCIDENT MILITARY TIME ACCIDENT SEVERITY #VEHICLES INVOLVED 1 PAI of#3 POLICE CASE NUMBER 1 0 2 0 2 0 .6 1 2 1 5 ❑Fatal ❑Injury NPDO 2 P200600390 TOWN OR CITY NAME TOWN CODE I ACCIDENT OCCURRED ON(Street Name or Route#)AT IT'S INTERSECTION WITH(Street Name or Route#) South Windsor 1 1 3 1 2 ELLINGTON RD(RTE 30) at CHAPEL RD FT] IF NOT AT INTERSECTION ❑ Feets Of Mile 2• DIRECTION 3. NAME OF NEAREST INTERSECTING STREET,TOWN LINE OR MILE MARKE 1 MEASURE DISTANCE [I❑ Tenth North❑ South of 4 ❑ Meters c 2 (Check Appropriate Boxes) El El Accident occurred: ❑ On Private Property ❑ Parking Lot ❑ Kilometers RE+ TRAFFIC © Vehicle El Pedestrian El Non-Contact Vechicle TRAFFIC p Vehicle ❑ Pedestrian ❑ Non-Contact Vechicle 2 02 1 , UNIT#1 UNIT#2 z 3 07, OPERATOR#1 or PEDESTRIAN NAME(Last,First,Middle Initial) OPERATOR#2 or PEDESTRIAN NAME(Last,First,Middle Initial) BONTA Kelly A. WILLET Scott T 2 32 ADDRESS(Street Number&Name) PROPER LICENSE CLASS ADDRESS(Street Number&Name) PROPER LICENSE CLASS 75 Union Street 18 11 Yes ❑ No 27 Sugar Hill Rd E Yes ❑ No CITY OR TOWN STATE ZIP CODE SEX CITY OR TOWN STATE ZIP CODE I SEX 21/ / 12 Rockville CT 06066 ❑ M O F Tolland CT 06084 ❑M ❑ F OPERATOR LICENSE# STATE DATE OF BIRTH- OPERATOR LICENSE# 7STATE DATE QF BIRTH 236855000 CT 1 r 1 11 r 0 7 8 I 083123061 0 8 2 r 0 1 5 i 7 OWNER'S NAME(Enter SAME If Owner is Operator) OWNER'S NAME(Enter SAME If Owner is Operator) Certified Auto Sales, SAME 2 K ADDRESS(Street Number and Name) ADDRESS(Street Number and Name) K / '1 32 Hartford Tpk,Vernon CT 2' K CITY OR TOWN STATE ZIP CODE BODY TYPE CITY OR TOWN STATE ZIP CODE BODY TYPE n / / Vernon CT AUTO AUTO REGISTRATION# STATE I VEHICLE YEAR AND MAKE REGISTRATION# STATE VEHICLE YEAR AND MAKE DE1291 CT 1998 FORD I I CT 1999 LEX `v08 VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER i F M Y U 2 1 Y X X W U I D 3 3 6 2 2 J T 6 H F 1 0 U 1 X 1 0 0 4 4 4 5 5 CARRIER NAME . ', CARRIER "CARRIER'ADDRESS"(#;Sttbet;City mTown,State;Zip Code) " CARRIER ADDRESS(#,Street,:City orTown,State,Zlp Code) SOURCE OF CARRIER,NAME` SOURCE OF CARRIER NAME CI.!uSDDT# ❑ uSDOT# Shipping Papers/Trip Manrfesl } ,❑ Shipping Papers 1 Trip Manifest ' ❑ iccMC#.J ❑ .ibcmc# ❑ Driver. ❑Side of Vehicle ' ❑.Drivar, ❑Side of Vehidle '- GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACECARD GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL RLACECARD, 2 1 "REQUIRED? ❑ yas ❑ Nu a Digit# REQUIRED?-❑Yes ❑ Np 4 Digd# TING# .RATING#', OISPLAYED? ❑ Yes:❑ Nei 'If _ ."DISPLAYED?❑Yes' ❑'No'1Digit# i - z HAZARDOUS'CARGO ENFORCEMENT ACTION TAKEN .HAZAIRDOUS CARGO ENFORCEMENT ACTION TAKEN None z ❑ None RELEASED-? ❑Yes❑No `, 0 Arrest ❑ Written warning ❑ Verbal Warning RELEASED?'❑Yes❑No ❑Arrest ❑written Warning ❑Verbal Wamin STATUTE OR ORDINANCE#'S SUBJECT operator carrier STATUTE OR ORDINANCE#'S suBJECT ❑ OF ❑O eretor ❑Carver 14-240 ACTION ❑Owner ❑Pedestrian N/A ACTION ❑owner ❑Pedestrian / , AUTOMOBILE INSURANCE--NAME-- POLICY# AUTOMOBILE INSURANCE--NAME-- POLICY# n / National Casualty-- CG 00021952 Safeco Ins-- K1643950 PARTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED n /' Front Rear End VEHICLE TOWED TO. ❑TOtnrED DUE TO DAMAGE VEHICLE TOWED TO. i❑TOWED DUE TO DAMAGE Ell,ia N/A I N/A 124 1: L. M. N. e e e • Date#B!,th0. P. 0. 1 1 N 01 TRAFFIC UNIT# 1 OPERATOR OR PEDESTRIAN# 4 2 1 1 z 2 2 N 01 TRAFFIC UNIT# 2 OPERATOR OR PEDESTRIAN# 4 2 1 2 z O O to to w 3 3 w OL a uw 4 4 w 5 5 >> > z J 6 6 1 Q Q 7 8 8