GOVERNMENT OPERATOR’S INCIDENT REPORT OF MOTOR VEHICLE ACCIDENT — 2013
DEPARTMENT OF PROPERTY AND PROCUREMENT GOVERNMENT OPERATOR’S INCIDENT REPORT OF MOTOR VEHICLE ACCIDENT Form No. DPP-004-DT-2013 | Approved 06/14/2013 | Commissioner of Department of Property and Procurement THIS FORM IS TO BE FILLED OUT BY THE GOVERNMENT OPERATOR AT THE TIME AND AT THE SCENE OF THE ACCIDENT, INSOFAR AS POSSIBLE. WRITE IN YOUR OWN WORDS HOW THE ACCIDENT OCCURRED DEPARTMENT / AGENCY NAME AND LOCATION OF ORGANIZATION TO WHICH YOU ARE ASSIGNED PLEASE PRINT FULL NAME RANK, RATING OR TITLE VIRGIN ISLANDS LICENSE NUMBER HOME ADDRESS (Street, City, State) TELEPHONE DATE AND DAY OF WEEK OF ACCIDENT HOUR (A.M. OR P.M.) PLACE OF ACCIDENT FROM WHAT LOCATION TO WHAT LOCATION WERE YOU TRAVELING? FOR WHAT PURPOSE? MAKE TYPE REGISTRATION NO. (or other Identification) PARTS OF VEHICLE DAMAGED (Describe) MAKE TYPE YEAR WAS THE VEHICLE EQUIPPED WITH SEAT BELTS? [ ] YES [ ] NO OPERATOR’S STATE LICENSE NUMBER VEHICLE LICENSE NUMBER IF YES, WERE THEY IN USE AT TIME OF ACCIDENT? …
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DEPARTMENT OF PROPERTY AND PROCUREMENT GOVERNMENT OPERATOR’S INCIDENT REPORT OF MOTOR VEHICLE ACCIDENT Form No. DPP-004-DT-2013 | Approved 06/14/2013 | Commissioner of Department of Property and Procurement THIS FORM IS TO BE FILLED OUT BY THE GOVERNMENT OPERATOR AT THE TIME AND AT THE SCENE OF THE ACCIDENT, INSOFAR AS POSSIBLE. WRITE IN YOUR OWN WORDS HOW THE ACCIDENT OCCURRED DEPARTMENT / AGENCY NAME AND LOCATION OF ORGANIZATION TO WHICH YOU ARE ASSIGNED PLEASE PRINT FULL NAME RANK, RATING OR TITLE VIRGIN ISLANDS LICENSE NUMBER HOME ADDRESS (Street, City, State) TELEPHONE DATE AND DAY OF WEEK OF ACCIDENT HOUR (A.M. OR P.M.) PLACE OF ACCIDENT FROM WHAT LOCATION TO WHAT LOCATION WERE YOU TRAVELING? FOR WHAT PURPOSE? MAKE TYPE REGISTRATION NO. (or other Identification) PARTS OF VEHICLE DAMAGED (Describe) MAKE TYPE YEAR WAS THE VEHICLE EQUIPPED WITH SEAT BELTS? [ ] YES [ ] NO OPERATOR’S STATE LICENSE NUMBER VEHICLE LICENSE NUMBER IF YES, WERE THEY IN USE AT TIME OF ACCIDENT? [ ] YES [ ] NO OPERATED BY (Full Name) VEHICLE OWNED BY (Full Name) OPERATOR’S HOME ADDRESS(Street, City, State) OWNERS ADDRESS (Street, City, State) SIGNATURE OF OPERATOR DATE PARTS OF VEHICLE DAMAGED (Describe) ENSURE THAT ALL QUESTIONS ARE ANSWERED COMPLETELY. SIGNATURE OF HEAD OF AGENCY DATE OTHER VEHICLES OR PROPERTY DAMAGED (Describe) SECTION I OPERATOR SECTION II TIME AND PLACE OPERATOR’S STATEMENT OF ACCIDENT AND USE OF SAFETY EQUIPMENT ESTIMATED AMOUNT OF DAMAGE $................................................... SECTION III YOUR VEHICLE ESTIMATED AMOUNT OF DAMAGE $................................................... SECTION IV OTHER VEHICLES AND PROPERTY (for additional vehicles see page 2) IF MEDICAL AID RENDERED, STATE BY WHOM WHERE WAS INJURED TAKEN NAME HOME ADDRESS CONDITION OF OTHER DRIVER IF OTHER DRIVERS OR PERSONS INJURED MADE A STATEMENT AS TO THE CAUSE OF ACCIDENT AND EXTENT OF PERSONAL OR PROPERTY DAMAGE, RELATE CONVERSATION, NAMES AND ADDRESSES OF OTHERS HEARING SUCH STATEMENT NAME TYPE YEAR OPERATOR’S STATE PERMIT NUMBER VEHICLE LICENSE NUMBER OPERATED BY OWNED BY ADDRESS (Home) OWNER’S ADDRESS (Business) PARTS OF VEHICLE DAMAGED (Describe) POLICE OFFICER BADGE NO. PRECINCT OR HQS. OTHER PROPERTY DAMAGED (Describe) YOUR VEHICLE OTHER VEHICLE DIRECTION OF TRAVEL DIRECTION OF TRAVEL XII. INDICATE BY DIAGRAM BELOW WHAT HAPPENED SIDE OF STREET OR HIGHWAY SIDE OF STREET OR HIGHWAY 1. Number Government vehicle as 1, other vehicle as 2 and additional vehicle as 3, and show direction of travel by arrow. Example: 2.Use solid line to show path before accident Broken line after accident 3. Show pedestrians by ______, O 4.Give names or numbers of street or highways. 5. Indicates north by arrow in this circle. APPROXIMATE SPEED (MPH) APPROXIMATE SPEED (MPH) CONDITIONS OF ROADWAY (Wet or dry, etc.) WEATHER CONDITIONS (Clear, foggy, rain, etc.) TYPE OF ROADWAY (Concrete, asphalt, etc.) XIII. LIST THE AMOUNT OF MOVING VIOLATIONS AND DATES THAT THE GOVERNMENT OPERATOR HAS BEEN INVOLVED WITHIN A ONE (1) YEAR PERIOD, OR WHETHER THE GOVERNMENTEMPLOYEE HAS BEEN CONVICTED FOR A VIOLATION OF THE PROVISION OF TITLE 20, SECTION 492 OR 493, VIRGIN ISLANDS CODE (OPERATING MOTOR VEHICLES IN A RECKLESS MANNER OR DRIVING UNDER THE INFLUENCE OF INTOXICATING LIQUORS OR CONTROLLED SUBSTANCES). OTHER INFORMATION (Indicate stop signs, traffic lights, obstructions, etc.) MOVING VIOLATION DATE OF VIOLATION MOVING VIOLATION DATE FO VIOLATION 1 2 1 2 SECTION V PERSONS INJURED SECTION VI OCUPANTS IN YOUR VEHICLE SECTION VI OCUPANTS IN OTHER VEHICLE SECTION VIII WITNESS AND POLICE SECTION IX THE ACCIDENT SECTION X EVENTS AFTER THE ACCIDENT SECTION XI OTHER VEHICLE AND PROPERTY SECTION XII ACCIDENT DIAGRAM AND OTHER VIOLATIONS