Loading...
HomeMy WebLinkAboutApplication Files_82693_pg0251 R09 CONNECTICUT UNIFORM POLICE ACCIDENT REPORT FORM PR-1 REV. 01/01 — GPS READINGS: Lattitude: ti A 1 � u Longitude: �y. 1 Time FOR DOT USE ONLY DATE E OF ACCIDENT !JILITARY TIME ACCIDENT SEVERITY #VEHICLES INVOLVED PAGE# POLICE CASE NUMBER 3 1z\ 1 0 9 016 2 1 3 0 ❑Fatal ❑Injury �PDO 2 1 of 3 P200603927 TOWN OR CITY NAME TOWN CODE I ACCIDENT OCCURRED ON(Street Name or Route#)AT ITS INTERSECTION WITH(Street Name or Route#) South Windsor 1 1 3 1 2 CHAPEL RD at JOHN FITCH BLVD(RTE 5) E 1 IF NOT AT INTERSECTION ❑ Feet 2•DIRECTION 3. NAME OF NEAREST INTERSECTING STREET,TOWN LINE OR MILE MARKE 1.MEASURE DISTANCE ❑ Tenths Of Mile❑ North❑ South of 4 t eers c 2 (Check Appropriate Boxes) ❑ M ❑ East ❑ West Accident Occurred: ❑ On Private Property ❑ Parking Lot ❑ Kilometers 02" " 0 TRAFFIC p Vehicle El Pedestrian ❑ Non Contact Vechicle TRAFFIC pp Vehicle ❑ Pedestrian El Non-ContactVechicle 2 2 1 r UNIT#1 UNIT#2 z 3 01 , OPERATOR#1 or PEDESTRIAN NAME(Last,First,Middle Initial) OPERATOR#2 or PEDESTRIAN NAME(Last,First,Middle Initial) GREER Dirk W PRIOR Jane Sz 31 ADDRESS(Street Number&Name) PROPER LICENSE CLASS ADDRESS(Street Number&Name) PROPER LICENSE CLASS 99 Apothecaries Hall ❑ Yes E No 1042 Main Street E Yes ❑ No CITY OR TOWN STATE ZIP CODE SEX CITY OR TOWN STATE ZIP CODE SEX Z'/ Broad Brook CT 06016 0 M ElF South Windsor CT 06074 O M O F / OPERATOR LICENSE# STATE DATE OF BIRTH OPERATOR LICENSE# STATE DATE OF BIRTH 188342566!D Card CT n ..6., 0 7 16 ,.,8. I 1221QQ17R1 CT 1 0 0 1 8 13 .8 OWNER'S NAME(Enter SAME If Owner is Operator) v OWNER'S NAME(Enter SAME If Owner is Operator) GREER,Susan L SAME K ADDRESS(Street Number and Name) ADDRESS(Street Number and Name) 99 Apothecaries Hall,South Windsor CT Z' / K CITY OR TOWN STATE ZIP CODE BODY TYPE CITY OR TOWN STATE ZIP CODE BODY TYPE zz / / South Windsor CT 06074 AUTO AUTO REGISTRATION# STATE VEHICLE YEAR AND MAKE REGISTRATION# STATE VEHICLE YEAR AND MAKE 811TMA CT 2005 FORD 268SMT CT 2000 CHEV `908 VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER 1 F A F P 3 4 N 9 5 VV 1 1 1 5 2 6 6 3 G N F K 1 6 T Z Y G 1 1 5 8 0 1 5 4 CARRIER:NAME CARRIER NAME,, CARRIER ADDRESS t#,Street„City off State,Zip Code)`, CARRIER ADDRESS(#,Street,City or Town;State;Z!p Code} SOURCE OF CARRIER NAME ❑ USpoT# '- SOURCE OF CARRIER NAWIE © °USDaT# :Shipping Papers/Tnp Manifest ❑ Shipping;Papers l Trip Manifest ❑'SICCMC# ,. ❑ Ice C# . .Driver :[]Stde,of�Vehwle ,[) hover ❑Side of Vehicle, / ❑ No LACE'CARD�' GROSS VEHICLE WEIGHT R QZARRDDOUSO 5 E❑RIAN PLACECARD - i''/_' GROSS VEHICLE WEIGHT HAZARDOUS MATERI' ogn# RATING# REDUIRED? ❑ vas. RATING# DISPLAYED?,❑ Yes"El,No 1Digilr#" DISPLAYED,?E Ve ❑ No_Cigitffi s z HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN ❑ None HAZARDOUS CARGO ENFORCEMENT ACT10N TAKEN None Z, RELEASED%.7 ❑Yes,❑N IT)- Arrest El Written blaming ❑ Verbal Waming RELEASED? ❑Yes❑No . ❑Arrest ❑Written Warnin ❑Verbal Wamin s / STATUTE OR ORDINANCE#'S suBJEcr o erator ca rier STATUTE OR ORDINANCE#'S SUBJECT ❑K P ❑ OF ❑Operator ❑Carrier 14-240 14-224 14-36 a ACTION ❑owner E]Pedestfi- N/A ACTION ❑owner ❑Pedestrian AUTOMOBILE INSURANCE--NAME-- POLICY# AUTOMOBILE INSURANCE--NAME-- POLICY# '/. / z Liberty Mutual-- A02-212-101887-21 6 Farm Family Casualty— 0602P109601 PARTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED u;/: Rear End �" / .A'Aa Front End / TOWED DUE TO DAMAGE VEHICLE TOkNED TO: ❑TOWED DUE TO DAMAGE VEHICLE TOVvcD TO, u� PA N/A I NIA I za l- L. M. N. Date of Birth O. P. Q. 1 1 N 01 TRAFFIC UNIT# 1 OPERATOR OR PEDESTRIAN# fj! q 2 1 1 0 2 2 N 01 TRAFFIC UNIT# 2 OPERATOR OR PEDESTRIAN# 4 3 1 2 z W of 3 3 a w a a LU 0 4 4 > 0 5 5 ° z z 6 g a 7 7 Q 8 8 1