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COLLISION FORM <br /> Driver's Name: Driver's Lic. No. n, Lic. Plate <br /> No. <br /> Make of Vehicle: Model: Yr. VIN No. <br /> Date: Time: !11 VF <br /> Location of Collision: <br /> ii <br /> Specific Damages to the vehicle you were <br /> driving: <br /> I <br /> Conditions: <br /> t Pavement ❑ Dry ❑ Wet ❑ Ice ❑ Snow Weather Visibility <br /> Traffic Control ❑ Lights ❑ Signal ❑ None— indicate any traffic control on the schematic you draw <br /> M Police Investigation ❑ Yes ❑ No Officer Name and Badge No. : <br /> Name of Department: <br /> * Request a copy of the police report for submission to the insurance company <br /> Were citations issued? ❑ Yes ❑ No If yes, to whom and for what violation? <br /> Other Motorists involved in the incident: <br /> Name: Address:. <br /> L Phone Number: Drivers License Number: <br /> L Lic. Plate No. Make of Vehicle <br /> Model Yr. VIN No. <br /> Owner of Vehicle Insurance Company'Name: <br /> Policy and Phone Number: <br /> Vehicle Speed <br /> y Direction of Travel: ❑ N ❑ E ❑ S o W Description of Damage ; w <br /> .i <br /> Name: Address: <br /> �K{ r <br /> I <br /> Attachment 6 <br /> I .;i <br />