HomeMy WebLinkAboutApplication Files_82693_pg0266 CONNECTICUT UNIFORM POLICE ACCIDENT REPORT FORM PR-1 REV.01101 ROS —
GPS READINGS: Lattitude: z;'
Longitude: a 1
Time: FOR DOT USE ONLY
DATE CF ACCIDENT MILITARY TIME ACCIDENT SEVERITY ~l#VEHICLES INVOLVED PAGE# POLICE CASE NUMBER
1
r.,:enu Jav fear 1 0 6
0 2 1 6 0 7 1 1 1 2 5 1 9 ❑Fatal Minjury ❑PDO 2 I — P200700509
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 E 1
IF NOT AT INTERSECTION ❑ Feet 2. DIRECTION 3. NAME OF NEAREST INTERSECTING STREET,TOWN LINE OR MILE MARKS
` 4
1.MEASURE DISTANCE ❑ Tenths Or Mile❑ North❑ South of
❑ Meters c 2
(Check Appropriate Boxes) Mt ❑ East ❑ West Accident Occurred: ❑ On Private Property ❑ Parking Lot
❑ Kilometers
02, TRAFFIC Vehicle ❑ Pedestrian ❑ UNIT#2 Non-Contact Vechicie TRAFFIC
UNIT#1 El Vehicle ❑ Pedestrian El Non-Contact Vechicle 2 02
1 + s 1
OPERATOR#1 or PEDESTRIAN NAME(Last,First,Middle Initial) OPERATOR#2 or PEDESTRIAN NAME(Last,First,Middle Initial) 2
01+ ROBERTS Gregory POTIEZ Jane M : 01
ADDRESS(Street Number&Name) PROPER LICENSE CLASS ADDRESS(Street Number&Name) PROPER LICENSE CLASS
1364 Ellington Rd 0 Yes ElNo P-11 Saint Marc Circle O Yes ElNo
J /
/ " CITY OR TOWN STATE ZIP CODE/ 1 2 SEX CITY OR TOWN STATE ZIP CODE SEX
J
South Windsor CT 06074 [] M ❑ F South Windsor CT 06074 El ElF F T
OPERATOR LICENSE# STATE ,t)ATE RF BIRTH. OPERATOR LICENSE# STATE DATE OF BIRTH
�d:;ntti a .r I wtth 1 flat 1171RFd5R CT 1 .1 10 .R 18 .1 152270997 ICT 1ivl1 1 12' 0 15 r 2 I
OWNER'S NAME(Enter SAME If Owner is Operator) OWNER'S NAME(Enter SAME If Owner is Operator)
7-9 FAiRtiIAN Ann C Potiez Daniel z�
ADDRESS(Street Number and Name) ADDRESS(Street Number and Name) K
K
/ ++ 1364 Ellington Road,South Windsor CT P-11 Saint Marc Circle,South Windsor CT K /
CITY OR TOWN STATE ZIP CODE BODY TYPE CITY OR TOWN STATE ZIP CODE BODY TYPE /
/ 12 South Windsor CT 06074 AUTO South Windsor CT 06074 AUTO
REGISTRATION 11 STATE I VEHICLE YEAR AND MAKE REGISTRATION 11 I STATE VEHICLE YEAR AND MAKE
351TML CT 2005 CHEV 997ROP CT 2002 FORD w03
VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER
1 G I 1 I J I C 5 2 1 F 6 5 7 1 1 4 6 3 5 1 F A F P 5 3 U 3 2 A 1 8 2 1 0 4
CARRIER NAM€ CARRIER NAME
}
CARRIER ADDRESS # Street Clry or Town State ZJp Code} CARRIER RD€7RESS(# Sfreet CityorToWr> State Tp Code}
az
SOURCE OFCARRIER NAME ySDoT SOURCE OF CARRIER NAME Q u3DOT
Shrpping_PaperslTnpMaafest>_ ❑ ShppmgPaparalTnfrt»anrfes4
x [:Q DnVer []$rde of Vehlcle � ICCAgG# � ' s � Dever [I$icte-of Vet+ipe; � tG'CMC#
f GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL Pt ACECARD GROS5II£HICLE WEIGF{{- #iAZARDOU5 MATERIAL PLACECARD
' ,:❑ xee {2EOUlRED 1 }ves [ Na d D @Its
Y FtATlNG# ❑ No 40p# #?AT1tIG a r-
41SPLAYED� ❑ Yes�];_No yDt@Y#, DtSP[AIED?CIY .fl,No;l
REQUIRED 1,
, l,:l
HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN ❑ Nana HAZA1j0US ERGO rENFORCEMENT ACTION TAKEN❑ None
'� R-ELEASED 7i❑`res❑No-x= Arrest ❑ Wtdten Wamiog ❑ Verbal Warning _R><t-I:�SE�,2 Na,,.�' EIA-st ❑Written Waming ❑Verbal Wamin 2'."�..
' STATUTE OR ORDINANCE#'S suaJECT Ooparator ❑carrier STATUTE OR ORDINANCE#'S OOFeJECT —Operator
N/A ACTION ❑Owner ❑ca ier
14-299 ACTION ❑Ovmer ❑Pedestrian ❑Pedestrian
AUTOMOBILE INSURANCE-NAME- POLICY# AUTOMOBILE INSURANCE-NAME-- POLICY# /
National Grange Mutual-- 01 B44647 The Phoenix-- 913739404 101 1
y� PARTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED /
Front End Front End&Driver Side
VEHICLE TOWED TO: GTO'JJED DUE TC DAf°1AGE VEHICLE TOWED TO: t1 TOWED DUE TO DAMAGE
T.. .€ Connecticut Auto Rescue Caron Auto
• + • •••` • " • • • Date of Birth O, P. Q,
L. M. N.
1 C 01 TRAFFIC UNIT#1 OPERATOR OR PEDESTRIAN#1 4 1 1 1
co
z Z pZ C 01 TRAFFIC UNIT#2 OPERATOR OR PEDESTRIAN#2 4 1 1 2 zo
W nonin ]ay vesr
W 3 W WHITIN Lisa B -- 115 High St South Windsor CT 06074 1 2 1 2 6 0 3 w
w
n o-
fr`ronih Gay "Year.
uJ
4 ,lonth ,ay ear 4 >
5 5 z
L .:Omit L,iy ea!
6 g -r
J .. J ..
�oncn .)ay Yee-
7 Q
KOI im av ,ar 7
8 8