CITY OF BROKEN

OPERATOR'S TRAFFIC COLLISION REPORT FORM INSTRUCTIONS: 1. State law requires that vehicle drivers must immediately stop at the scene, render aid and exchange information when involved in a traffic collision. Drivers must assure that all debris is removed from the roadway before leaving the scene. 2. Obtain driver's license and insurance information from the other driver's License and Security Verification Form. 3. Complete all information on both sides of this report form. Type or print with black ink. 4. Your information should be listed in the Unit 1 section. Information for the other vehicle shall be indicated as Unit 2. 5. Use additional report forms when more than two (2) vehicles are involved. Change unit numbers to 3, 4, etc. 6. Contact your insurance company as soon as possible. 7. Completed report forms should be sent to the Broken Arrow Police Department at the address listed on the bottom of the report form within 24 hours. Make additional copies for your records.

Date Day of Time A.M. Did a Police Officer respond Yes Officer's Name the Week P.M. to the Collision? No Street location Was your view blocked by Yes If Yes, Explain: of Collision anything at the time of the collision? No Total Number of Weather Conditions at Approximate cost to Vehicles Involved the time of the Collision repair your vehicle? $ Your Name (Unit 1) Last Name First Middle Name (Unit 2) Last Name First Middle

Home Address City State Zip Home Address City State Zip

Business Address Business Address

Home Phone Business Phone Home Phone Business Phone

Driver Information Date of Birth Age Sex Male Injured Yes Date of Birth Age Sex Male Injured Yes Female No Female No Driver's License State Mo/Yr Driver's License State Mo/Yr Number Expiration Number Expiration Vehicle Make Model Color Vehicle Year Make Model Color Year Vehicle License State Vehicle License State Mo/Yr of

Mo/Yr of Number Expiration Number Expiration Vehicle Owner's Name Vehicle Owner's Name Same as Driver Same as Driver Insurance Company Insurance Company

Effective Date of Vehicle Information Policy Number Effective Expiration Policy Number Date Date Date Expiration Insurance Agent Phone Insurance Agent Phone

How fast were you driving What was the posted What is your estimated What was the other prior to the collision? MPH Speed Limit? MPH speed of the other vehicle? MPH vehicle's Posted Speed Limit? MPH Speed Riding in Unit "X" if Injured Passenger Name Address Phone Age Number

1.

2.

3.

4.

PassengerInformation 5.

6. Witness Name Address Phone

1.

2.

3.

Witness Information 4. Signature Date Time A.M. X P.M. : The reporting of or fraudulent information may result in criminal and/or civil prosecution Broken Arrow Police Department I assume responsibility for any damages resulting from this collision. Records Division

1101 N. 6th Street Print Name: Broken Arrow, OK 74012 Signature: Date:

COLLISION

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