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Date <br />LI A.M. <br />Time ID P.M. <br />Department Badge # <br />Address <br />Phone Insurance Co. <br />va Or <br />Driver <br />Truck/Tractor No. _ Trailer No. <br />Were any mechanical defects apparent at the time of <br />the accident? Explain <br />(Town, City, State) Were you wearing safety belts? <br />Roadway <br />(Rt. #, Street, Intersecting Hwys) <br />Landmark <br />(Near bridge, milepost, etc.) <br />Persons Killed <br />Persons Injured <br />Was anyone taken away from scene for medical <br />treatment (Who & Where Taken) <br />INVESTIGATION <br />Was Accident Investigated by Police? <br />Officer <br />Citation Issued? <br />List persons cited or arrested & charges <br />Type Make <br />Model Year <br />Driver <br />Address <br />License # & State <br />Owner <br />VEHICLE NO. 3 <br />Type Make <br />Model <br /> <br />Year <br />Driver <br />Address <br />License # & State <br />Owner <br />Address <br />Phone Insurance Co. <br />Place <br />YOUR VEHICLE <br />DEATH AND INJURY <br />VEHICLE NO. 2 <br />ACCIDENT DATA