Late Accident Report Form
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1
2LATE ACCIDENT REPORT FORM
GUILFORD POLICE DEPARTMENT
400 CHURCH STREET
GUILFORD, CT 06437
DATE OF ACCIDENT
DAY OF WEEK
TIME
#OF VEHICLES
POLICE CASE NUMBER
(MONTH) (DAY) (YEAR)
INVOLVED
/
/
AM
PM
CITY OR TOWN (NAME)
ACCIDENT OCCURRED ON (Street name or route #)
AT INTERSECTION WITH (street name or route #)
IF NOT AT INTERSECTION
1. Give distance and check either
2. Check Direction
3. Give next intersecting street (name or route #)
“feet” or “tenths” of a mile
or location of parking lot.
( ) Feet
N
S
E
W
( ) Tenths
( ) ( ) ( )
( )
of __________________________________________________
OPERATOR AND VEHICLE #1
OPERATOR AND VEHICLE #2
(or just vehicle if parked)
Operator # 1
NAME (last, first, middle initial)
Operator #2
NAME (last, first, middle initial)
ADDRESS (Street, number and name)
ADDRESS(Street, number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
Lic State/ Operator License Number
DATE OF BIRTH
Lic State/Operator License Number
DATE OF BIRTH
/
/
/
/
/
/
VEHICLE #1 OWNER NAME (if same as operator #1, enter, same)
VEHICLE #2 OWNER NAME(if same as operator #2, enter, same
ADDRESS (street number and name)
ADDRESS(street number and name)
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
PLATE # AND STATE CODE
VEHICLE YEAR AND MAKE
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE MODEL NAME
BODY TYPE (e.g. 4 door sedan, truck)
VEHICLE IDENTIFICATION NUMBER(not engine number)
VEHICLE IDENTIFICATION NUMBER(not engine number)
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
NAME OF AUTOMOBILE INSURANCE CO
POLICY #
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
PARTS OF VEHICLE DAMAGED (e.g. left front fender, etc)
VEHICLE #1 TOWED TO (if not towed, indicate “none”)
VEHICLE #2 TOWED TO (if not towed, indicate “none”)
DAMAGE TO
1. Described the property and extent of damage (e.g. 50 feet of fence knocked down)
PROPERTY
_____________________________________________________________________
OTHER THAN
2. Give Name and Address of property owner
INVOLVED
______________________________________________________________________
VEHICLES
AGE
SEX
NAME AND ADDRESS OF WITNESS
AGE
SEX
NAME AND ADDRESS OF WITNESS
INSTRUCTIONS:
1. Fill in ALL known information.
2. Indicate unknown information by using “UNK”
3. If you need assistance confer with your attorney or insurance agent and return completed form to this department.
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