Fillable Private Property Traffic Crash (Pittsfield Charter Township)

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Private Property Traffic Crash (Pittsfield Charter Township)

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The Private Property Traffic Crash (Pittsfield Charter Township) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Pittsfield Charter Township

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1. The driver of either vehicle is under the influence of alcohol or drugs.
2. The collision involves reckless driving.
3. Personal injuries occurred.
4. The collision occurred on a public street.
5. The license plate number of a hit and run vehicle was obtained by a witness.
Filing a false report is a crime.
Private Property Traffic Crash
Pittsfield Township Police Department
INSTRUCTIONS
Dear Citizen,
The attached form is intended to provide a speedy and self-reporting system for your Private Property Vehicle crash that
occurred in Pittsfield Township.
DO NOT USE THIS FORM IF THE COLLISION INVOLVES ANY OF THE FOLLOWING:
(Dial 911 to have a Police Officer dispatched to investigate the crash if ANY apply.)
INSTRUCTIONS FOR COMPLETION
Step One:
Complete all requested information on the
attached form as indicated.
(Please see example at left).
Step Two:
Make necessary copies for your records. You may
need a copy for your insurance company.
Step Three:
Mail, fax, e-mail or bring a copy of the report to
the Pittsfield Township Police Department.
Mailing Address:
Pittsfield Township Police Department
Records Bureau
6227 W. Michigan Avenue
Ann Arbor, MI 48108
Fax:
734-944-0744
E-Mail:
Publicsafety@pittsfield-mi.gov
Drop-Off Hours:
Monday-Friday 8:00 am - 4:00 pm
QUESTIONS??
Please call the Records Bureau at:
734-822-4930
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Private Property Crash
Pittsfield Township Police Department
Note: Knowingly providing false information on this form could result in the offending party being prosecuted for filing a false police report.
VIN: The vehicle identification number (VIN) is printed on your vehicle registration. It can also be found on your dashboard under the lower driver’s
side of the windshield or on the driver’s side front door pillar.
TYPE OR PRINT WITH BLACK INK
LOCATION AND/OR ADDRESS OF CRASH:
TIME AND DATE
DRIVER’S NAME, WITNESS
DOB
HOME ADDRESS CITY STATE
DAYTIME PHONE
DRIVER’S LICENSE NUMBER STATE
E-MAIL
VEHICLE A:
VEHICLE IDENTIFICATION NUMBER:
VEHICLE YEAR
VEHICLE MAKE, MODEL & COLOR
VEHICLE TYPE (2 DOOR, VAN, PICK-UP ETC..)
LICENSE PLATE NUMBER LICENSE PLATE STATE
REGISTERED OWNER NAME, ADDRESS, PHONE NUMBER (Complete only if different than the name above.)
INSURANCE COMPANY AND POLICY NUMBER
INDICATE ANY DAMAGE FROM THIS CRASH ON THE VEHICLE BY MARKING
THE NUMBER MOST CLOSELY CORRESPONDING TO THE AREA OF DAMAGE.
BRIEF EXPLANATION OF HOW VEHICLE WAS DAMAGED:
DRIVER’S NAME, WITNESS
DOB
HOME ADDRESS CITY STATE
DAYTIME PHONE
DRIVER’S LICENSE NUMBER STATE
E-MAIL
VEHICLE B:
VEHICLE IDENTIFICATION NUMBER:
VEHICLE YEAR
VEHICLE MAKE, MODEL & COLOR
VEHICLE TYPE (2 DOOR, VAN, PICK-UP ETC..)
LICENSE PLATE NUMBER LICENSE PLATE STATE
REGISTERED OWNER NAME, ADDRESS, PHONE NUMBER (Complete only if different than the name above.)
INSURANCE COMPANY AND POLICY NUMBER
INDICATE ANY DAMAGE FROM THIS CRASH ON THE VEHICLE BY MARKING
THE NUMBER MOST CLOSELY CORRESPONDING TO THE AREA OF DAMAGE.
BRIEF EXPLANATION OF HOW VEHICLE WAS DAMAGED:
OTHER PROPERTY DAMAGED OTHER THAN VEHICLES (I.E. TREES, SIGNS, BUILDINGS, ETC..)
Police use only
INCIDENT NUMBER
DATE AND TIME RECEIVED RECEIVED BY
PAGE 1 OF
CLASS
DISPOSITION
NOTES:
NOTE TO INSURANCE COMPANY: This crash was not investigated by the Pittsfield Township Police Department. This form was
completed by the persons listed in boxes A & B above.
Rear
Front of
vehicle
Rear
Front of
vehicle
DELIVERY METHOD
DATE AND TIME COMPLETED
INTENTIONALLY LEFT BLANK
WAS THIS INCIDENT
A HIT & RUN?
YES
NO
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Private Property Traffic Crash (Pittsfield Charter Township)

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Completed 9 February 2021

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