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HomeMy WebLinkAboutApplication Files_82693_pg0254 ' CONNECTICUT UNIFORM POLICE ACCIDENT REPORT FORM PR-1 REV.01/01 e08 — GPS READINGS: Lattitude: 1 ' Time: Longitude: ^ FOR DOT USE ONLY DATE OF ACCIDENT MILITARY TIME ACCIDENT SEVERITY #VEHICLES INVOLVED PAGE# POLICE CASE NUMBER 1 Month Day Year of 4 1 1 0 1 2 1 E 0 1 7 1 1 3 1 5 ❑Fatal [:]Injury IDEPDO 2 1 P200703789 ' TOWN OR CITY NAME TOWN CODE I ACCIDENT OCCURRED ON(Street Name or Route#)AT ITS INTERSECTION WITH(Street Name or Route#) 1 South Windsor 1 1 3 1 2 ELLINGTON RD(FITE 30) at CHAPEL RD E� IF NOT AT INTERSECTION ❑ Feet 2•DIRECTION 3< NAME OF NEAREST INTERSECTING STREET,TOWN LINE OR MILE MARKE 1.MEASURE DISTANCE [I North El South of 4 ❑ Tenths Of Mile G (Check Appropriate boxes) ❑ Meters ❑ East ❑ West Accident Occurred: ❑ On Private Property ❑ Parking Lot 2 ❑ Kilometers 02", TRAFFIC TRAFFIC " 02 ' 1 , UNIT#1 ❑ Vehicle ❑ Pedestrian ❑ Non Contact Vechicle UNIT#2 Vehicle El Pedestrian ❑ Non-Contact Vechicle 0, Zi 01 OPERATOR#1 or PEDESTRIAN NAME(Last,First,Middle Initial) OPERATOR#2 or PEDESTRIAN NAME(Last,First,Middle Initial) MOFFAT-ALLEN Vivia E LEWIS Laura B : 01 ADDRESS(Street Number&Name) PROPER LICENSE CLASS ADDRESS(Street Number&Name PROPER LICENSE CLASS ' 10 Dorothy Or 10 J ElYes ❑ No 708 Twin Circle Or 0 Yes ❑ No/ " CITY OR TOWN STATE ZIP CODE SEX CITY OR TOWN STATE ZIP CODE SEX a'/ / 12 Bloomfield CT 06002 ❑ M ❑ F South Windsor CT 06074 ❑M El F / OPERATOR LICENSE# STATE DATE QF BIRTH OPERATOR LICENSE# STATE DATE OF BIRTH IJwn�n ay Year Mon1h Dav Year ' 013526000 CT 0 .1 10 2 1,"3" 2a3n1".99 �CT t .o I n. l 5.6 OWNER'S NAME(Enter SAME If Owner is Operator) UWNERS NAME(Enter SAME If Owner is perator) SAME SAME ADDRESS(Street Number and Name) ADDRESS(Street Number and Name) / x 21 / ` 12 CITY OR TOWN STATE ZIP CODE BODY TYPE CITY OR TOWN STATE ZIP CODE BODY TYPE / AUTO AUTO REGISTRATION TSTATE VEHICLE YEAR AND MAKE REGISTRATION# STATE VEHICLE YEAR AND MAKE 114WCK 2000 CHEV 733MFL ICT 2004 MERC "'03 VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER 1 G 1 i 1 J I C 5 2 4 1 Y 7 2 1 7 1 2 1 4 1 0 2 4 M 2 Z U 8 6'K 9 4 Z J 2 9 0 2 8 CARRIER NAtyIE CARRIER(lAt�lE x ` -Ma CARRIER ADDRESS'(# Streef;CEty orTpwn Stake ZIp Code), 5 CARRIER ADDRESS(# Streef,CrtyorTown State Z p Cody}, f - ~ 4 SOURCE OF C4FtR1EFi NAME Q`uSDOTd SOURCE OF CARRIER NAhAEj srt UsooT l Shlppingi'apers f Trip Manifest _ _ ❑ Shlpp(pg P.epers P Trlp x O ❑ ❑ MOW-_ ❑ Dve nr ❑ hicl Ide of Vee Dnver SEdeofUehlCle xi. Y © GROSSUEHICLE WEIGHT HAZARDOUS MATERIAL PLACECARD GROSS'VEHICLE°WEIGHT' RAZARDOUS MATERIAL PLACECAtiD REQUIRED? Y R.ATING# --"r ❑ Yss❑":.No 4Digl{_� � t REQUIR�R?©Yea'� No 4-ptgt# DISPLAYEDJ,?i❑ Yes ❑?No t Digrt# RATING;# a a t DISPLAYED T❑Yes:❑ No t bigitk Z: HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN ❑ None HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN M None z,- "� t -RELEASED'?`QYesu IT] Arrest [I Written Warning ❑ Verbal Warning RELrEASED?,❑Yes= No^❑ - ❑Arrest ❑Written Warning ❑Verbal Warnin 2r. STATUTE OR ORDINANCE#'S SUBJECT ❑operator ❑Carrier STATUTE OR ORDINANCE SUBJECT OF OF ❑ []carrier Carrier 14-299 ACTION ❑Owner ❑Pedestrian N/A ACTION Downer ❑Pedestria AUTOMOBILE INSURANCE--NAME-• POLICY# AUTOMOBILE 1 RAN NAME-- POLICY# gn zt- Trumbull Ins Co-- 55 PHK293105-350222 Allstate-- 0 19 484798 / :1z PARTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED L ;3 Front End Front End VEHICLE.TOWED TO: Ex TOWED DUc Tn DAMAGE VEHICLE TOWED TO: ❑TOWED DUE TO DAMAGE CT Auto Rescue ' CT Auto Rescue(AAA) L. M. N. Date of Birth O. P. Q. 1 l N 01 TRAFFIC UNIT#1 OPERATOR OR PEDESTRIAN#1 4 1 1 1 ' 0 2 N 01 TRAFFIC UNIT#2 OPERATOR OR PEDESTRIAN#2 4 2 1 2 zO UJ Month, Day Year U) w 3 3 w Month Day Year ' LU 4 4 Ld J � Jon!n Year 0 5 MonthDay Year 5 0 a 6 6 a vlonm Day Yea, 7 iaon h ay Year 7 8 8 1