Fill and Sign the Kentucky 51a125 Form

STATE OF MAINE SNOWMOBILE, ATV, WATERCRAFT ACCIDENT REPORT FORM The Department of Inland Fisheries and Wildlife is responsible for documenting all reportable snowmobile, ATV & I Watercraft accidents which have at least one of the following: $1,000.00 or more which includes all property damage. This report must be filed within 72 hours of a property I 1. damage only accident and can be used to report a property damage accident. Property damage accidents I resulting in less than $1,000.00 which includes all property damage do not need to be reported. 1 Personal injury o r death. Any accident that causes a death or injuries that require the services of a physician have to be reported by the quickest means to a law enforcement officer and investigated by a law enforcement officer. This 72 hour form can p J be used for reporting this type of accident 2. Department of Inland Fisheries and Wildlife Recreational Safety Division 284 State Street 4 1 State House Station Augusta, Maine 04333 WITHIN 72 HOURS FOLLOWING ACCIDENT I DATE OF ACCIDENT: I PLACE DAY OF WEEK PLACE WHERE ACCIDENT OCC'IIRRED HOIJR COUNTY CITYiTOWN LOCATION WHERE ACCIDENT OCCIJRRED Give name of road, body of water, trail name or ITS number AT TRAIL INTEKSEC'I'ION WITH Road, another trail Vehicle # 1 LAST, FIRST, MIDDLE IjRIVER'S NAME D.0.B MO. DAY YEAR [I MALE Vehicle # 2 IAS1'. I'IKST.. MII>DI>E DRIVER'S NAME PHONI' NUMBER D 0 . B MO. DAY YEAR FEMALE CI'TYfl-0 WN YCAR II STATE ZIP II II MAKE I SERIAL NiJMBCR - - -- -- -- I'HOKE NUMBER - CIJRRENI' ADDRESS. NIJMHL.II P.Y1) S'I lil,l:T CITY/TOWN STA'TF! --- - - -- -- .- - t MAKE YEAR SFKIAI. WIJMBLIZ --- - - . - - - - t h 1 IMA TED COSr F O KLI'AIR - - F\1(blAr1 i l ( O \ l IORLI>AI!: If more than two vehicles were involved, describe the additional vehicles on separate report forms and attach to this report. TOTAL NUMBER OF VEHICLES INVOLVED: As a result of this accident, was anyone summonsed to court? Name of Court IYes 0 No Charge(s) Did a Law Enforcement Officer investigate at the scene of the accident? Name of Investigating Oficer Arrested? Yes 0 Yes n No 0 No Department: (Please Print) (IFW, State Police, Sheriff, Local Police, etc) WAS A POLICY OF LIABILITY INSURANCE COVERING THE VEHICLE YOU WERE DRIVING IN EFFECT AT THE TIME OF fl YES 0 NO 0 UNSURE ACCIDENT? FOR OFFICE USE ONLY DATE RECEIVED: ZIP DI;'>t7Uft3I Dl4b1A(~I r0 V i I i I C 1 I D1,SCKIBF. DAMACJC TO VEHICI I - blA1,I; [j I'EMAI,E 0 CHECK IF NEW ADDRESS 0 CHECK IF NEW ADDRESS ('IIRREN'T ADDRESS, NIJMBER AND S'1'REI:'I' i I I TIME 1 1 1 1 Please check all boxes below that pertain to the property damage accident you were involved in. 9. Surface Conditions 0 Debris 0 Calm 0 Choppy 0 Rough Very rough Strong current 1. Vehicle Type 0 A-N , Snowmobile Motor Vehicle Open Motorboat Cabin Motorboat Auxiliary Sail Sail 0 Rowboat 0 Canoe 0 other (please list) 0 Packed snow Powder snow Slush Ice covered I I 10. Personal Safety Equipment Used 2. Type Location Marked and groomed trail Unmarked and ungroomed trail 0 Bridge Open field 0 Gravel pit 0W d s 0 Muddy 0 Dry 0 Lake/Pond 0 RivedStream Approved lifejacket Lifejacket not approved net used 1 Ocean Helmet not used 0 None Road Othcr (please list) .- 3. Type Accident 0 Collision with another vehicle 0 Grounding 0 Capsizing Fire or Explosion (fuel) 0 Fire or explosion (non-fuel) Collision with vessel 0 Collision with fixed object [I Collision with floating object Falls overboard Falls in boat Hit by propeller 4. Object Struck Other vehicle (type) Gate or cable Waterway marker 5 Bridge, pier, float or dock Floating object [1 Pressure ridge 0 R.R. cross& device Utility pole 0 Poles, posts or supports 0 Fire hydrantlparking meter 1 1. Vehicle Safety Equipment Utilities property 0 No Yes 13. Member of a Club 0 No 0 Tree Yes Guard rails 0 Fenc~ng Culvert headwall Embankment 0 Building, wall Rock outcrop, ledge 0 Other (please list) 14. Pre-Accident Actions-Maneuvers By Vehicle 0 Cruising 0 Other (please list) Unknown 0 None [I Light (0 - 6 mph) Moderate (7 - 14 mph) 15. Pre-Accident Actions-Maneuvers By Pedestrian Fog, smog, smoke Standing Getting onioff vehicle 0 Pushing or working on vehicle Skin divingfswimming 0 Blowing sand or dust 0 Cloudy 0 other (please list) I I DESCRIBE WHAT HAPPENED (Refer to vehicles by number) Current mailing Address SIGN ~ / ~ o uvehicle ~ No.1 Signature of I I K I V K 0 Skiing [I Other pedestrian action Does not apply Unknown 16. Apparent Contributing Factors Hunian [I Operating inattention 0 No improper action Operating in unfamiliar area Fail to yield right of way 0 Fell or thrown off Unsafe speed Failure to use lights Following to close 0 Operator inexperience 0 Disregard trail or waterway markers Physical impairment Improper passfovertaking 0 Vision obscured 0 lmproper turn 0 Hit and run Unsafe backing Impeding traffic 0 Unknown Strong (I5 - 20 mph) Storm (25+ mph) Vehicular [I Clothing tangled Stuck throttle Defective brakes Defective lights 0 Defective tires HERE Slowing in traffic Stopped in traffic Avoiding vehicle, object, 0 pedestrian, animal 0 Skidding Overtaking, passing Backing 0 Parked 0 Operating on a public wav 0 Operating on a private way Other vehicular action 0 Unknown n 7. Weather-Atmosphere Clear Rain Snow Sleet, hail, freezing rain Making right turn Rafting CanoeingKayaking At anchor Tied to dock Fueling Fishing Hunting 0 Following trail 0 Other (please list) I 0 Making left turn 0 Making U turn 0 Starting from park [I Approaching dock Water skiing 1 1 Racing0 Towing 1 Being towed Drifting Dark (no street lights) Daylight (I Dusk Dark (street lights on) NIA 12. RV Safety Training completed? 6. Light 0 Dawn 0 Wet suit Throw bags Inside lines 5. Other Property Damage 0 State properly 0 Outside lines 0 Fire extinguisher Submersion [I Bums [I Rear end sideswipe Head on sideswipe Ran offtrail 0 Rollover 0 Train 0 Animal Pedestrian 0 Other (please list) [I Defective suspension 0 Defective steering 0 Other vehicle defect or failure 0 Unknown I Date