MOTOR VEHICLE COLLISION STATEMENT

Driver's Information

Last Name:

Middle Name(s):

First Name:

Date of Birth:

Physical Address:

Gender

Male Female Other

Email

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Driver's Licence Number

Province of Issue:

Consent

Full Name

Date

Victim Services

A victim of an offence who has suffered physical or emotional loss has the right to prepare a Victim Impact Statement. If a charge is laid and the accused found guilty, the Victim Impact Statement will be considered by the judge at the time of sentencing. If you wish to provide a Victim Impact Statement you may contact Victim Services, or a member of the Victim Services Unit can contact you.

Date

Describe the Collision

Today's Date and Time:

Collision Date and Time:

Location of Roadway (Road, Highway, Nearest Community or Landmark )

Direction of Travel

North

South

East

West

Were Police Called?

Yes

No

Did Police Attend Scene?

Yes

No

Is this a Hit & Run?

Yes

No

Was your Vehicle?

Parked

In motion

Do you believe alcohol or drugs were a factor?

Yes

No

Your Vehicle Information

Make:

Model:

Year:

Serial Number(VIN):

Colour:

License Plate:

Province of Issue:

Estimated Damage to Your Vehicle

Are you the Registered Owner of the Vehicle?

Yes

No

If no, please complete the following information:

Full Name of Owner

Phone Number:

Address

Trailer Information if Applicable

Make:

Model:

Year:

Colour:

License Plate Number:

Province:

Serial Number:

Insurance Company Information

Insurance Company

Policy Number

Agent

Expiry Date

Safety Equipment Used

1-LAP BELT ONLY
2-LAP/SHOULDER BELT
3-SHOULDER BELT ONLY
4-LAP/SHOULDER BELT WITH AIRBAG
5-AIRBAG ONLY (NO BELT WORN)

6-CHILD SAFETY/BOOSTER SEAT
7-HELMET (ATV, MOTORCYCLE, ETC.)
8-NONE
9-OTHER
10-UNKNOWN

Front Passengers Name

Date of Birth

Address

Phone

Rear Driver's Side Passenger Name

Date of Birth

Address

Phone

Were there any Injuries?

Yes

No

Was anyone admitted to the hospital?

Yes

No

Was anyone treated but not admitted to the hospital?

Yes

No

Please list any injuries

Road Conditions

Road:

Good Poor Holes Oily Soft Under Construction Other

If other, please explain:

Road Surface:

Dry Wet Slush Snow Ice Muddy Lose Material Other

If other, please explain:

Intersection Related:

Yes No

Railroad Crossing

Yes No

How fast were you travelling?

Have you had any alcohol to drink in the last 24 hours?

Yes No

Were you distracted?

Yes No

Was there any defect of any kind to your vehicle that contributed to the collision?

Yes No

Please describe:

Please describe the area of impact on your vehicle

Other Vehicle(s) Involved

Name of Driver:

Make:

Model:

Year:

Colour:

Insurance Information:

License Plate:

Province:

Name of Driver:

Make:

Model:

Year:

Colour:

Insurance Information:

License Plate:

Province:

Insurance Information:

Witness Information

Name of Witness

Describe in detail the events of the collision as you recall them. Please include the direction of travel and actions of all vehicles involved in the collision.

You may go to www.ecollision.gov.ab.ca to print off your copy of the report at home. Note: this can only be done once the investigation is completed which could take several weeks depending on the severity of the collision. If you have not been provided your Ecollision number, please call the Tsuut’ina Nation Police Service to obtain it. Alternatively a copy of the T.S.S will be mailed to you once the investigation is complete.

Drivers License

Registration

Driver's Information

Consent

Victim Services

Describe the Collision

Your Vehicle Information

Trailer Information if Applicable

Insurance Company Information

Safety Equipment Used

Road Conditions

Other Vehicle(s) Involved

Witness Information