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Traffic Collision Statement

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Sheriff Office

sheriff@co.valley.id.us

Contact information for at least one vehicle driver/owner, to include full name, date of birth, address and phone number, must be included, or the report cannot be entered and will be discarded.

DRIVER’S INFORMATION

*First Name

*Middle Initial

*Last Name

*Address

*City

*State

*Postal Code

*Date of Birth

(mm/dd/yyyy)

Cell Phone #

Home Phone #

Work Phone #

Occupation

Employer

*Date of Collision

*Time of Collision

Please note for simplicity, the street on which the accident occurred will be referred to as "Street 1", and the nearest cross-street to the accident will be referred to as "Street 2".

*Street 1

Street 2

ACCIDENT INFROMATION

*Light Conditions

*Road Type

*Weather Conditions

*Road Surface

*Direction of Travel

*Driving Action

What Type of Protection device used (check all that apply,)

Lap and shoulder belt

Lap

Helmet

*Does your Vehicle have Airbags?

*Did your Airbags Deploy?

Which Airbags? (Check all that Apply)

Driver

Passenger

Driver's Side

Passenger's Side

*Were you injured?

Where?

How many people were in vehicle?

How many people were injured?

Any mechanical problems prior:

*Posted Speed Limit

*Your Speed

*Any Vision Obstructions:

Describe:

*Have you been on this road before:

INSURANCE INFORMATION

*Insurance Company

*Policy #

*Agents Name

*Agents Phone #

VEHICLE INFORMATION

*License Plate

*Expiration Date

(mm/dd/yyyy)

*Year

*Make

*Model

*Color

Attached trailers vehicle?

VEHICLE OWNER'S INFORMATION

*Owner’s Name

*Address

*City

*State

*Zip Code

Home Phone #

Work Phone #

Cell Phone #

OTHER VEHICLES

*Was there another vehicle involved?

If Yes where was it?

# Vehicles Involved

If there are more involved vehicles please explain were they were.

Other Driver’s Information

Driver’s Name

Address

City

State

Zip Code

Phone #

Insurance Company

Policy Number

If there were additional driver's list them.

(Name, Address, Phone #, Insurance Company and Policy #.)

List all occupants in the vehicle below:

Passenger One

Name

Last, First

Date of Birth

(mm/dd/yyyy)

Address

City

State

Zip

Phone Number

Sex

Seating Position

Seatbelt

Child seat

Injured during accident:

Passenger Two

Name

Last, First

Date of Birth

(mm/dd/yyyy)

Address

City

State

Zip

Phone Number

Sex

Seating Position

Seatbelt

Child Seat

Injured during accident:

Passenger Three

Name

Last, First

Date of Birth

(mm/dd/yyyy)

Address

City

State

Zip

Phone Number

Sex

Seat Position

Seatbelt

Child Seat

Injured during accident:

Passenger Four

Name

Last, First

Date of Birth

(mm/dd/yyyy)

Address

City

State

Zip

Phone Number

Sex

Seating Position

Seatbelt

Child Seat

Please list any additional passengers with the same information provided for the first four passengers.

Injured during accident:

*Be Specific and Describe what Happened:

*Upload pictures of the accident (Drawing or Photos)

ADMONITION – IDAHO CODE SECTION 18-705

*I have read and understand all writing on this page. All information is true and accurate.

*Electronic Signature (Type Your Full Name)

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General Information

Staff Directory

Captain

David Stambaugh

(208) 382-7155

dstambaugh@co.valley.id.us

Lieutenant

Kevin Copperi

(208) 382-7155

kcopperi@co.valley.id.us

Sheriff

Patti Bolen

(208) 382-7150

(208) 382-7170

sheriff@co.valley.id.us

Phone Numbers

(208) 382-7150

Fax: (208) 382-7170

Emergencies: Dial 911

Location

107 W. Spring Street

Cascade,

83611

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Sheriff Kevin Copperi

Traffic Collision Statement

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