DEPARTMENT OF PROPERTY AND PROCUREMENT

GOVERNMENT OPERATOR'S INCIDENT REPORT OF MOTOR VEHICLE ACCIDENT



Form No. DPP-004-DT-2013 | Approved 06/14/2013 | Commissioner of Department of Property and Procurement



WRITE IN YOUR OWN WORDS HOW THE ACCIDENT OCCURRED



THIS FORM/IS TOBE FILLED OUT BY THE GOVERNMENT OPERATOR AT THE TIME



AND AT THE SCENE OF THE ACCIDENT, INSOFAR AS POSSIBLE.



DEPARTMENT / AGENCY



WAS THE VEHICLE EQUIPPED WITH SEAT BELTS? [ ] YES



[ ]NO



[ ] YES



IF YES, WERE THEY IN USE AT TIME OF ACCIDENT?



[ ]NO



OPERATOR’S STATEMENT OF ACCIDENT AND USE OF SAFETY EQUIPMENT



SIGNATURE OF OPERATOR



ENSURE THAT ALL QUESTIONS ARE ANSWERED COMPLETELY.



SIGNATURE OF HEAD OF AGENCY



SECTION IV



OTHER VEHICLES AND PROPERTY

(for additional vehicles see page 2)



— of | NAMEAND LOCATION OF ORGANIZATION TO WHICH YOU ARE ASSIGNED

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S & | PLEASE PRINT FULL NAME

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RANK, RATING OR TITLE VIRGIN ISLANDS LICENSE NUMBER

HOME ADDRESS (Street, City, State) TELEPHONE

DATE AND DAY OF WEEK OF ACCIDENT HOUR (A.M. OR P.M.)

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_ < PLACE OF ACCIDENT

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5 2 FROM WHAT LOCATION TO WHAT LOCATION WERE YOU TRAVELING?

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| FOR WHAT PURPOSE?

MAKE TYPE REGISTRATION NO. (or other

= 4 Identification)

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z | PARTS OF VEHICLE DAMAGED (Describe)

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ESTIMATED AMOUNT OF DAMAGE $...ccsccssessseccssesssnsssecssscsscsesessnecsnves

MAKE TYPE YEAR

OPERATOR'S STATE LICENSE NUMBER VEHICLE LICENSE NUMBER



OPERATED BY (Full Name) VEHICLE OWNED BY (Full Name)



OPERATOR'S HOME ADDRESS(Street, City, State) OWNERS ADDRESS (Street, City, State)



PARTS OF VEHICLE DAMAGED (Describe)



ESTIMATED AMOUNT OF DAMAGE S.....:.ccssccsscsesseceseseesteensteeeesreeeees



OTHER VEHICLES OR PROPERTY DAMAGED (Describe)

SECTION VI



SECTION VI



IF MEDICAL AID RENDERED, STATE BY WHOM WHERE WAS INJURED TAKEN



TITLE 20, SECTION 492 OR 493, VIRGIN ISLANDS CODE (OPERATING MOTOR VEHICLES IN A

RECKLESS MANNER OR DRIVING UNDER THE INFLUENCE OF INTOXICATING LIQUORS OR

CONTROLLED SUBSTANCES).



MOVING VIOLATION DATE OF VIOLATION



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F & | CONDITION OF OTHER DRIVER

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o F Wae@ IF OTHER DRIVERS OR PERSONS INJURED MADE A STATEMENT AS TO THE CAUSE

“gy z = OF ACCIDENT AND EXTENT OF PERSONAL OR PROPERTY DAMAGE, RELATE

a sia CONVERSATION, NAMES AND ADDRESSES OF OTHERS HEARING SUCH STATEMENT

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a NAME TYPE YEAR

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& rs OPERATOR'S STATE PERMIT NUMBER VEHICLE LICENSE NUMBER

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2 Ss & OPERATED BY OWNED BY

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” % Q | ADDRESS (Home) OWNER’S ADDRESS (Business)

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= 2 9 G@ | PARTS OF VEHICLE DAMAGED (Describe)

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5 POLICE OFFICER BADGE NO. PRECINCT OR HQS. OTHER PROPERTY DAMAGED (Describe)

YOUR VEHICLE OTHER VEHICLE

DIRECTION OF TRAVEL DIRECTION OF TRAVEL

XII. INDICATE BY DIAGRAM BELOW WHAT HAPPENED

SIDE OF STREET OR HIGHWAY SIDE OF STREET OR HIGHWAY wy | JcNlaniber Governnnmnt Vehicle ay 2: other vehicle asa ahd 3, Show pedestrians by fe)

FS additional vehicle as 3, and show direction of travel by arrow. 4,Give names or numbers of street or

APPROXIMATE SPEED (MPH) APPROXIMATE SPEED (MPH) F Example: ——> [I> C3] <— cnn oii bearowinitiibeddl

© | 2.Use solid line to show path before accident co O

yc | CONDITIONS OF ROADWAY (Wet or dry, etc.) a

= a 2 Broken line after accident ----- =)

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G &| WEATHER CONDITIONS (Clear, foggy, rain, etc.) TYPE OF ROADWAY (Concrete, asphalt, etc.) za

a EM Ill. LIST THE AMOUNT OF MOVING VIOLATIONS AND DATES THAT THE GOVERNMENT

F — S$ OPERATOR HAS BEEN INVOLVED WITHIN A ONE (1) YEAR PERIOD, OR WHETHER THE

OTHERINFDRMA TION Undicate stop sions, traffic Hahts, obstructions, er.) ME@ GOVERNMENTEMPLOYEE HAS BEEN CONVICTED FOR A VIOLATION OF THE PROVISION OF

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MOVING VIOLATION DATE FO VIOLATION