Persona involucrada (indique si es: chofer, pasajero, peatón, propietario):
Miembro de familia (indique parentesco):
Otra parte interesada, especifique:
Representante legal (Abogado, guardián, conservador)
Representante de la Companía Aseguradora o Agencia de Ajustadores (Debe ser la companía que tenia asegurada a la parte
interesada cuando occurió el accidente. Debera presentar el número de póliza o reclamación.) Número de Póliza o Reclamación:
Representante del Fabricante (Debe tener carta de autorización
del fabricante fechada dentro de los últimos 12 meses.)
Asegurado por sí mismo: Nombre:
Persona autorizada (Debe tener firma de autorización) Indique a quién representa:
Robo / recuperacion de vehículo
Descripción: Marca Modelo
Use previous editions until depleted.
ESTADO DE CALIFORNIA
LA PATRULLA DE CAMINOS DE CALIFORNIA
SOLICITUD PARA OBTENER INFORMACION
CHP 190 (Rev. 11-03) OPI 008
Chp190_0419.pdf
PARTY OF INTEREST (check and complete one ONLY)
USO INTERNO SOLAMENTE
NOMBRE Y DOMICILIO (use letra de imprenta)
FIRMA (DECLARO BAJO PENA DE PERJURIO QUE SOY LA PERSONA INTERESADA COMO ESTA
INDICADO ARRIBA)
Use previous editions until depleted.
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
APPLICATION FOR RELEASE OF INFORMATION
CHP 190 (Rev. 11-03) OPI 008
Chp190_0419.pdf
PARTY OF INTEREST (check and complete one ONLY)
OFFICE USE ONLY
Person involved (indicate whether driver, passenger, property owner, pedestrian, registered owner):
Family member (Indicate relationship):
Other party of interest, specify:
Legal representative (Attorney, guardian, conservator):
Representative of Insurance Company or Insurance Adjusting Agency (Must have been
a carrier for involved party at time of accident. Policy or claim number must be presented.)
Manufacturer Representative (Must have a letter from manufacturer
certifying authority dated within the last year.)
Self-Insured: Name:
Authorized person (Must have signed authorization). Indicate person represented:
Auto theft or recovery Vehicle description: Year:
PLEASE PRINT NAME AND ADDRESS
SIGNATURE ( I DECLARE UNDER PENALTY OF PERJURY THAT I AM THE PARTY OF INTEREST
AS CHECKED ABOVE)
COLLISION / INCIDENT DATE
REPORT NUMBER
COLLISION / INCIDENT LOCATION DRIVER OR OWNER RECEIPT NUMBER
Policy or Claim No.:
Manufacturer:
Certificate number:
Lic. or VIN No.
APPLICANT NUMBER AND STREET, CITY, STATE, ZIP CODE
AGENCY / COMPANY DATE
FECHA DE LA COLICIÓN / INCIDENTE
NÚMERO DE REPORTE
LUGAR DE LA COLICIÓN / INCIDENTE
CHOFER O PROPIETARIO
NÚMERO DE RECIBO
Fabricante:
Número de Certificado:
Placas de circulación o número de serie (VIN)
APLICANTE
NÚMERO Y CALLE, CIUDAD, ESTADO, ZONA POSTAL
AGENCIA / COMPANÍA
FECHA
DATE / TIME OF INTERVIEW
DATE:
FROM TO HOURS
DATE / TIME OF INTERVIEW
DATE:
FROM TO HOURS
DATE / TIME OF INTERVIEW
DATE:
FROM TO HOURS
DATE / TIME OF INTERVIEW
DATE:
FROM TO HOURS
RECORD OF INTERVIEW
RECORD OF INTERVIEW
RECORD OF INTERVIEW
RECORD OF INTERVIEW
INTERVIEWER REPRESENTING
LOCATION OF INTERVIEW
REGARDING (PURPOSE OF INTERVIEW)
MEMBER TO BE INTERVIEWED ID NUMBER APPROVED BY DATE APPROVED
INTERVIEWER REPRESENTING
LOCATION OF INTERVIEW
REGARDING (PURPOSE OF INTERVIEW)
MEMBER TO BE INTERVIEWED ID NUMBER APPROVED BY DATE APPROVED
INTERVIEWER REPRESENTING
LOCATION OF INTERVIEW
REGARDING (PURPOSE OF INTERVIEW)
MEMBER TO BE INTERVIEWED ID NUMBER APPROVED BY DATE APPROVED
INTERVIEWER REPRESENTING
LOCATION OF INTERVIEW
REGARDING (PURPOSE OF INTERVIEW)
MEMBER TO BE INTERVIEWED ID NUMBER APPROVED BY DATE APPROVED
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