Fillable State of Connecticut DEPARTMENT OF ADMINISTRATIVE SERVICES OFFICE (State of Connecticut/Department of Administrative Services)

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State of Connecticut DEPARTMENT OF ADMINISTRATIVE SERVICES OFFICE (State of Connecticut/Department of Administrative Services)

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BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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AGENCY NAME (INCLUDE REGION, DIVISION, BUREAU, UNIT) VEHICLE LICENSE PLATE #
NAME OF THE DRIVER’S SUPERVISOR EMAIL ADDRESS OF SUPERVISOR
DRIVER/VEHICLE INFORMATION
VEHICLE #1 - STATE OF CT VEHICLE VEHICLE #2 - OTHER VEHICLE/PROPERTY PEDESTRIAN/CYCLIST
DRIVER’S NAME DRIVER’S NAME
DATE OF BIRTH SEX
HOME ADDRESS HOME ADDRESS
CITY/TOWN STATE ZIP CITY/TOWN STATE ZIP
DRIVER’S WORK PHONE # DRIVER’S PHONE #
DRIVER’S WORK EMAIL ADDRESS OWNER OF VEHICLE (if different)
PLATE # STATE
YEAR MAKE MODEL
YEAR MAKE MODEL
VIN # VIN #
VEHICLE CATEGORY
ASSIGNED TO YOU POOL CAR
RENTAL
DESCRIBE NON VEHICLE PROPERTY DAMAGE IF APPLICABLE INCIDENT/ACCIDENT INFORMATION:
State of Connecticut
DEPARTMENT OF ADMINISTRATIVE SERVICES
OFFICE OF FLEET OPERATIONS
165 Capitol Avenue
Hartford, CT. 06106
INSURANCE COMPANY NAME & POLICY #:
INSURANCE COMPANY PHONE #
DAS Vehicle Incident/
Accident Report
DATE TIME
CITY / TOWN NO. OF VEHICLES
Location: Occurred on
_______________________________________________________
ROUTE/HGWY # OR STREET NAME
CLOSEST INTERSECTION
_____________________________________________________
ROUTE #, EXIT # OR STREET NAME
WAS YOUR VEHICLE TOWED Y N
WAS POLICE ACCIDENT
REPORT RECEIVED?
Y N
NAME OF POLICE DEPT. ON SCENE
NAME/BADGE # OF POLICE OFFICER
CASE #
INCIDENT INFORMATION
DATE OF BIRTH SEX
DATE OF BIRTH SEX
WAS MEDICAL ASSISTANCE CALLED TO THE SCENE Y N
IDENTIFY PERSON(S) REQUIRING MEDICAL ASSISTANCE
WERE THERE ANY WITNESSES TO THE INCIDENT Y N
PLEASE LIST WITNESSES NAME AND CONTACT INFORMATION
TYPE OF INCIDENT/ACCIDENT
COLLISION WITH: NON COLLISION WITH:
OTHER MOTOR VEHICLE OVERTURN
MOTOR VEHI. CROSSING MEDIAN SPILL
PARKED MOTOR VEHICLE FIRE
BICYCLIST SUBMERSION
PEDESTRIAN JACKKNIFE
ANIMAL EXPLOSION
THROWN OR FALLING OBJECT OTHER
MOTORCYCLE
FIXED OBJECT
IF ACCIDENT INVOLVED FIxED ObjECT (above)
CHECk THE ObjECT STRUCk:
TRAFFIC SIGNAL BARRIER/FENCE
SIGN POST EMBANKMENT
GUARD RAIL FIRE HYDRANT
CRASH CUSHION DITCH/CURB
LIGHT POLE PARKING METER
TELEPHONE POLE OTHER
TREE
BUILDING/WALL
BRIDGE/PIER
MEDIAN
ACCIDENT LOCATION
INTERSECTION RAMP/ROTARY
LOCAL STREET IN DRIVEWAY
ALONG THE ROAD IN PARKING LOT
ALONG ROAD @ DRIVEWAY ON HIGHWAY
OFF ROAD ON SHOULDER OTHER
OFF ROAD BEYOND SHOULDER
TRAFFIC CONTROLS
NONE VISIBLE ROAD MARKINGS
TRAFFIC SIGNALS OFFICER/FLAGMAN
STOP SIGN RR CROSSING FLASHER GATE
YIELD SIGN NO PASSING ZONE
LANE CONTROL OTHER
ROAD DESIGN
INTERSTATE ONE WAY
OTHER DIVIDED HWGHY DRIVEWAY
ROAD NOT DIVIDED (2-WAY) ACCESS WAY
OTHER
ROAD CONDITIONS
DRY DEBRIS
WET SAND/DUST/OIL
SNOW/SLUSH POT HOLE
ICE UNDER CONSTRUCTION
MUDDY OTHER
WEATHER CONDITION
CLEAR
FOGGY
CLOUDY
RAINING
SLEETING
SNOWING
OTHER
DESCRIbE INCIDENT:
LIGHT CONDITION
DAYLIGHT
SUNGLARE
DAWN/DUSK
NIGHT – ROAD LIT
NIGHT – ROAD NOT LIT
DESCRIbE DAMAGE Vehicle 1 DESCRIbE DAMAGE Vehicle 2
Check box(es) representing
vehicle damage area.
Check box(es) representing
vehicle damage area.
FRONT
REAR
FRONT
REAR
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State of Connecticut DEPARTMENT OF ADMINISTRATIVE SERVICES OFFICE (State of ConnecticutDepartment of Administrative Services)

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Completed 13 August 2020

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