Fill and Sign the Amberton University Transcript Request Form

PERSONAL REPORT OF ACCIDENT This form should be completed when a traffic accident occurs and a law enforcement officer is not called to make a report. This report is for your personal use and should not be mailed to the Department of Driver Services, as it will be destroyed upon receipt. Time INSTRUCTIONS: 1. Answer all questions to the best of your knowledge. If unable to answer any questions, mark “not known”. 2. Give exact time of accident (date, day and hour). 3. Under “Location of Accident” show sufficient information to locate exact scene of the accident. 4. Print or type all names and addresses. 5. Sign the report in the space provided on the reverse side. 6. Report must be complete as to exact names, birth dates, and drivers license numbers. 7. Use a second report form or a sheet of plain paper of the same size to report additional vehicles, injured persons, or witnesses, or any other information for which there is insufficient space. L O C A T I O N V E H I C L E S Space for any third vehicle on reverse side. Total vehicles involved Date of Accident________ Place Where Accident Occurred: Day of Week________ Hour______A.M.______P.M. Weather________________________________ (Clear, Raining, Fog, Etc.) DO NOT WRITE IN THIS SPACE City, Town County________________________ Or Township __________________________ If accident was outside city _______ miles _______ limits indicate distance from " limits of south-north nearest town. Use two disof _______ miles _______ tances and two directions City or Town " center of east-west if necessary. ROAD ACCIDENT OCURRED ON:______________________________________________________________________________________ Give name of street or highway number, (U.S. or State). If no highway number, identify by name. { }{ " At its intersection with: Check and OR complete one " Not at intersection: } ___________ _______________________________________________________ Name of intersecting street or highway number _______ feet _______ south-north _______ feet _______ east-west { } of _______________________________ show nearest intersecting street or highway, house number, bridge, driveway or other identifying landmark. YOUR VEHICLE NUMBER 1 Vehicle Approximate cost _________________________________________________ License Plate _________________________________ to repair vehicle _______________ Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number Driver________________________________________ ________________________________________________________________________ Full Name Street City and State Driver’s Driver’s Driver’s Occupation____________________________________ License________________________ Birth Date__________________Age_____Sex_______ Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr Owner_____________________________________________________________________________________Owner’s Birth Date_________________ Full Name Street City and State Mo Da Yr Parts of Owner’s Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________ Is this vehicle covered by " Yes IF YES TO EITHER SHOW State Number Name ________________________________________________________ automobile liability insurance? " No INSURANCE COMPANY Show name of insurance company not name of insurance agency. If vehicle not covered, did driver " Yes _______________________ have liability policy applicable? " No Show Policy Number Here Address_______________________________________________________ OTHER VEHICLE NUMBER 2 Vehicle Approximate cost _________________________________________________ License Plate _________________________________ to repair vehicle _______________ Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number Driver________________________________________ _________________________________________________________________________ Full Name Street City and State Driver’s Driver’s Driver’s Occupation____________________________________ License________________________ Birth Date__________________Age_____Sex_______ Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr Owner_____________________________________________________________________________________Owner’s Birth Date_________________ Full Name Street City and State Mo Da Yr Parts of Owner’s Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________ State Number Is this vehicle or driver covered by automobile liability insurance? " Yes " No If Yes show name of Insurance Company_________________________ DAMAGE TO PROPERTY Approximate OTHER THAN VEHICLE___________________________________________________________________________ cost to repair $____________________ NAME OBJECT AND STATE NATURE OF DAMAGE NAME AND ADDRESS OF OWNER OF DAMAGED PROPERTY________________________________________________________________________________ 3rd V E H I C L E I N J U R E D Vehicle No. 3 (If third vehicle Involved) Vehicle Approximate cost _________________________________________________ License Plate _________________________________ to repair vehicle _______________ Year Make Type (sedan, truck, taxi, bus, etc.) Year State Number Driver________________________________________ _________________________________________________________________________ Full Name Street City and State Driver’s Driver’s Driver’s Occupation____________________________________ License________________________ Birth Date__________________Age_____Sex_______ Carpenter, Sales Clerk, Etc. State Number Mo. Da Yr Owner_____________________________________________________________________________________Own er’s Birth Date_________________ Full Name Street City and State Mo Da Yr Parts of Owner’s Vehicle Damaged_______________________________________________Driveable " Yes " No Driver License ____________________________ State Number Is this vehicle or driver covered by automobile liability insurance? " Yes " No If Yes show name of Insurance Company_________________________ " Driver In Vehicle " Passenger No.____________ Name__________________________________________________Address_______________________________ " Pedestrian Injured Age________ Sex________ Race________ taken to__________________________________________________ " Specify other_______________ Nature and Attending Did injured die?_______________ extent of injuries__________________________________________ Doctor_________________________________ Name__________________________________________________Address_______________________________ Injured Age________ Sex________ Race________ taken to_______________________________________________ Nature and Total Injured Did injured die?_______________ extent of injuires__________________________________________ Light Conditions " Daylight " Dawn or Dusk " Darkness What Pedestrian Was Doing Pedestrian was going " " " " N S E W " Crossing or entering at intersection " " " " Attending Doctor_________________________________ " Across or into_________________________From___________________To____________________ Street name, highway no. " Walking in roadway-with traffic " Pushing or working on vehicle " Other in roadway " Crossing or entering not at intersection " Walking in roadway-against traffic " Other working in roadway " Getting on or off vehicle Driver In Vehicle Passenger No.____________ Pedestrian Specify other_______________ " Standing in roadway " Not in roadway " Playing in roadway What Drivers Intended To Do: (Check one for each driver) Driver 1 2 " " " " " " 3 " " " Driver 1 2 3 Go straight ahead Overtake and pass Make right turn " " " " " " " " " Make Left Turn Make U Turn Make right turn Driver 1 2 3 " " " " " " " " " Start in Traffic Start from parked position Back Driver 1 2 3 " " " " " " " " " Remain stopped in traffic lane Remain Parked Get out of parked or stopped vehicle Witnesses: Name_________________________________________________________ Address__________________________________________ Age________________ approximate Name__________________________________________________________ Address___________________________________________ Age________________ approximate DESCRIBE WHAT HAPPENED: Refer to vehicles by number. If more space is needed, use another report form or a sheet of plain paper of the same size. _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Signature________________________________________________ Address___________________________________________________ Date_______________ Signature of person submitting report is required. Complete both sides of this form.