| Note: Reports cannot be picked up in person, they can only
be mailed or faxed back to you. Availability of reports may vary
on a case by case basis.
Today's
Date: ________ / ______ / 200___
Type of Report Requested (Circle one):
-
Accident
-
Fatal Accident
-
Theft
-
Criminal Damage
-
Other (please explain)______________________
Date of Incident:_________________
Location of Incident:____________________________
Names of Drivers:____________________________________________
Names of Passengers: ____________________________________________
Names of Property Owners:
____________________________________________
Your Name: ____________________________________________
Your Address: _______________________________________________________
Your Phone/Fax Number:
____________________________________________
Your Relationship to
incident (Circle one)
-
I was personally involved
in above incident
-
I am a parent of a minor
involved in above incident
-
I am the owner of property
stolen or damaged in above incident
-
Insurance Company* (please
attach the proper fee for type of report requested)
-
Other (please explain)_____________________________________________
(*All third parties are charged
a handling fee of $5 for per report. The fee for a motor vehicle
accident report that involved reconstruction is $20.) Please mail
this completed form to the address at the top of this page. All reports
will be mailed/faxed back to you as soon as possible. If we have
any questions about your request we will call you. Thank you for
your cooperation. |