ࡱ> |{C Objbj 8:hh3&&8\`,thhhhHJJJJJJ$= "`nnhhHFhhHHhP6J40S#@S#S#<nnS#&X ~: THE ACCIDENT / INCIDENT Date of Accident:__________ Time:________  FORMCHECKBOX  AM  FORMCHECKBOX  PM Location of Accident:__________________________________ Town/City:__________________________________________ Nearest Landmark:____________________________________ Weather Conditions:___________________________________ Road Conditions:_____________________________________ Police Dept:_________________________________________ Investigating Officer:__________________________________ STATE VEHICLE (#1) Driver:______________________________________________ Home Address:_______________________________________ Town:______________________ State:______ Zip:__________ Date of Birth:____________ Drivers License #:_____________ Dept:________________ Bureau/Division:_________________ Direct Supervisor:_____________________________________ Vehicle Year, Mark, Model:_____________________________ Plate #______________________Mileage:_________________ Description of Damage:________________________________ Estimate of Damage $__________________________________ Is this an authorized emergency vehicle?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is this a Central Fleet Management Vehicle?  FORMCHECKBOX  Yes  FORMCHECKBOX  No IF THERE IS DAMAGE TO CFM VEHICLE, CONTACT THEM AS SOON AS POSSIBLE AT 1-800-300-7013 WITHIN MAINE OR 207-287-5521 OTHER VEHICLE (#2) Driver:_____________________________________________ Street Address:_______________________________________ Town:______________________ State:______ Zip:_________ Phone #_____________ Email:__________________________ Drivers Date of Birth:____________ License #_____________ Owner:_____________________________________________ Street Address:_______________________________________ Town:______________________ State:______ Zip:_________ Phone #_____________ Email:__________________________ Vehicle Year, Make, Model:_____________________________ Plate #______________________________________________ Description of Damage:________________________________ Insurance Agent or Company:___________________________ Address:____________________________________________ Phone #__________________ Policy #____________________ Were other vehicles/drivers involved?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any other property damage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please provide information on the back or a separate form. INJURED PERSONS Were there any injuries reported?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, you MUST call Risk Management Division immediately at 1-800-525-1252. Name of injured person:________________________________ Address:____________________________________________ Location in Accident:__________________________________ Description of injury:__________________________________ Date of Birth:_______ Phone #____________________ Name of injured person:________________________________ Address:____________________________________________ Location in Accident:__________________________________ Description of injury:__________________________________ Date of Birth:_______ Phone #____________________ DESCRIPTION OF ACCIDENT / INCIDENT ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Use additional space on back to complete description or draw a diagram. Photos are helpful, even if there is no damage. PASSENGERS OR WITNESSES Name:______________________________________________ Address:____________________________________________ Location in accident:___________________________________ Name:______________________________________________ Address:____________________________________________ Location in accident:___________________________________ I HAVE READ AND COMPLETED THIS ACCIDENT / INCIDENT REPORT. THIS STATEMENT IS CORRECT TO THE BEST OF MY KNOWLEDGE. 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