Police Department Personal History Statement Form Page 18
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2258. List all traffic collisions within the past 10 years in which you were the driver:
Date of collision __________________________________ Location of accident ___________________________________
Law-enforcement agency investigation _____________________________________________________________________
Were you at fault for the accident?
Yes No
Were you issued a citation?
Yes No
If yes, explain _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of collision __________________________________ Location of accident ___________________________________
Law-enforcement agency investigation _____________________________________________________________________
Were you at fault for the accident?
Yes No
Were you issued a citation?
Yes No
If yes, explain _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of collision __________________________________ Location of accident ___________________________________
Law-enforcement agency investigation _____________________________________________________________________
Were you at fault for the accident?
Yes No
Were you issued a citation?
Yes No
If yes, explain _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of collision __________________________________ Location of accident ___________________________________
Law-enforcement agency investigation _____________________________________________________________________
Were you at fault for the accident?
Yes No
Were you issued a citation?
Yes No
If yes, explain _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of collision __________________________________ Location of accident ___________________________________
Law-enforcement agency investigation _____________________________________________________________________
Were you at fault for the accident?
Yes No
Were you issued a citation?
Yes No
If yes, explain _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
59. Are your vehicles licensed in Idaho?
Yes No
60. Idaho State Code requires every vehicle operated in Idaho to have liability insurance.
List your insurance carrier, policy number and expiration date. __________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
61. Has your automobile insurance ever been cancelled?
Yes No
If yes, indicate reason: __________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
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