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HomeMy WebLinkAboutApplication Files_82693_pg0294 R08 CONNECTICUT UNIFORM POLICE ACCIDENT REPORT FORM PR-1 REV.01/01 GPS READINGS. Lattitude. 5" A 1 Longitude: � t Time: , : FOR DOT USE ONLY 1 ° 1 DATE OF ACCIDENT MILITARY TIME ACCIDENT SEVERITY #VEHICLES INVOLVED PAGF# POLICE CASE NUMBER 'Month 2 a7 01 8 1 1 2 0 ❑Fatal ❑Injury ❑PD0 2 1 0 4 P200803876 1 0 Route# AT IT'S INTERSECTION WITH Street Name or Route M) 1 ' TOWN OR CITY NAME TOWN CODE ACCIDENT OCCURRED ON(Street Name o ) f South Windsor 1 3 2 ELLINGTON ROAD at CHAPEL ROAD E 1 IF NOT AT INTERSECTION 0 Feei 2•DIRECTION 3 NAME OF NEAREST INTERSECTING STREET,TOWN LINE OR MILE MARKER FTJ 1 MEASURE DISTANCE ❑ Tenths Of Mile❑ North❑ South Of G2 (Check Appropriate Boxes) ❑ Meters ❑ East ❑ West Accident Occurred: ❑ On Private Property ❑ Parking Lot ❑ Kilometers _ 02 1 " 02 TRAFFIC TRAFFIC ❑ Vehicle ❑ Pedestrian ❑ Non-Contact Vechicle 2 1 UNIT#1 © Vehicle ❑ Pedestrian ❑ Non-Contact Vechicle UNIT#2 5 2 01; OPERATOR#1 or PEDESTRIAN NAME(Last,First,Middle Initial) OPERATOR#2 or PEDESTRIAN NAME(Last,First,Middle Initial) 2 Fitch Alva S Singleton Mikel 2 18 ADDRESS(Street Number&Name) PROPER LICENSE CLASS ADDRESS(Street Number&Name) PROPER LICENSE CLASS 4 Amato Dr I ❑ Yes ❑ No 325 Ellington Rd ❑ Yes ❑ No ! / „ z, CITY OR TOWN STATE ZIP CODE SEX CITY OR TOWN STATE ZIP CODE SEX F.! South Windsor CT 06074 ❑ M O F South Windsor CT 06074 V p M ❑ F OPERATOR OR LICENSE# STATE I D TE e�r,r-BIRy}j OPERATOR LICENSE# STATE ^"TE OF BIRTH ' Nionfh Day r tear M1tOrdh :ay Year 222309795 CT 1 0 1 3 4 6 178202499 ICT O 5t0 710 4 OWNER'S NAME(Enter SAME If Owner is Operator) OWNER'S NAME(Enter SAME If Owner is Operator) SAME SINGLETON HOSEA Z ADDRESS(Street Number and Name) ADDRESS(Street Number and Name) / +K 325 ELLINGTON RD,SOUTti WINDSOR CT 2' ! CITY OR TOWN STATE ZIP CODE BODY TYPE CITY OR TOWN STATE ZIP CODE I BODY TYPE /F / 12 AUTO SOUTH WINDSOR CT 06074 AUTO REGISTRATION TscitA TE VEHICLE YEAR AND MAKE REGISTRATION# STATE VEHICLE YEAR AND MAKE 305SRVT 2003 TOYA 820WPA CT 1998 PONT O-3- VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER 4 IT 11 IB JE 13 12 IK 19 13 JU 12 12 19 12 11 15 1 G 2 W P 5 2 K 3 W F 2 1 0 311 14 GARRIER;NAME s 4 , s ,{ k ' CARRtEI�NAME f4 f sxa�s CARRIERADpRESG(#Street Ctty orToWn State Z1p Code), T CARRIER ADDRESS(# S{reet Giy&Tl lbwn "State Z Code) t x 3 SOURCE OF CARRIER�M� $ _ � SOURCE OF CARRIER NAME [ USDOT# ❑ Shlpp,ngPaperslTrtpManlfast � USDDT#�r R r� {� StnppmgPap,3rsTTilpManlfests '` � ❑'ICCMC# [) ptiver�`'❑Slrfe ofV"etalcle � ❑ tCGMC# � .i❑ Dn3er (]Stde of Vehicle z, € ` 2 GROSS VEHICLE WEIGHT hIAZARDOtlS MATERIAL PLACECARD GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACECARD ' RFQUIREDT❑ Yes(] No aopxu EOD1REp Yes No g0igil# Y :RATING# r DISPLAYED? ©Yea Q No t:Digxl✓ "�—_ � 4 f DISPL`AYED'7 Yes No to(gi{# z HAZARDOUS CARGO r ENFORCEMENT ACTION TAKEN ❑ None HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN None r z ' ".i2ELEAS{Ei7`7,.l�'eat❑No.,,.,' ArrestElWritten WamIng ❑ Verbal Warning ;RELEASED,7cI7res❑No _ �- ❑Arrest ❑Written Wamin ❑Verbal Warnn z suaJECT STATUTE OR ORDINANCE#'S OF ION STATUTE OR ORDINANCE#'S OF Dope ator ❑ca rier of ❑operator ❑tamer 14-299 ACTION ❑Owner [:]Pedestrian ACTION ❑Owner ❑Pedestrian AUTOMOBILE INSURANCE--NAME-- POLICY# AUTOMOBILE INSURANCE--NAME-- POLICY# ' PEERLESS INSURANCE-- PLB4371987 ALLSTATE INSURANCE-- 9 19 33970$06l29 12 PARTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED AA a FRONT END -, FRONT LEFT SIDE 23 VEHICLE TOWED TO: QTOWED DUE TO DAMAGE VEHICLE TOWED TO: TOWED DUE T o DAMAGE rd tARRYS AUTO I BERNIES AUTO L. M. N. 7JDate of Birth O. P. Q. 1 C 01 TRAFFIC UNIT#1 OPERATOR OR PEDESTRIAN 91WL1.1 2 1 .1 ' U) 2 C 01 TRAFFIC UNIT#2 OPERATOR OR PEDESTRIAN#2 Jr 1 2 O O rn w 3 W STEVENS EDWARD B -- 5 AUTUMN DRIVE SOUTH WINDSOR CT 06074 0 3 0 5 4 5 3 a ' d Month Day year 0 4 W Martocchio Vincent -- 290 Foster Street South Windsor CT 06074 0 8 2 7 7 1 4 ul Monti), Day I ear —� 5 5 z Month Day Year 6 6 J Q OMh � ay Year 7 7 1 1 1 1 V ont ay Year 8 8 1K I _