Forms

2. Location:*
4. Accident Date and Time
   Accident Date and Time

   Accident Date and Time
6. Did this occur on

   1. Private Property

   1. City Street
8. First Name
9. Last Name*
11. Address1*
13. Address2
15. City
16. State
17. Zip
19. Home/Cell Phone*
21. Email*
23. Confirm Email*
25. Race
27. DOB*
29. Driver's License No*
30. Licensing State*
32. Safety Devices*

    1. Not Applicable
    2. None Used
    3. Lap Belt
    4. Shoulder and Lap Belt

    1. Helmet Used
    2. Air Bag Deployed
    3. Airbag Deployed/Shoulder Lap Belt
34. Passenger*

    1. There were other people in the vehicle I was driving and I have their information.
    2. There were other people in the vehicle I was driving and I do not have their information.
    3. I was alone in the vehicle.
36. Passenger Name
37. Phone
39. Enter Vehicle Information
    Please enter YOUR vehicle information
41. Accident Type*

    Choose only one

    1. Vehicle Only
    2. Pedestrian
    3. Pedalcycle

    1. Animal
    2. Off Highway Vehicle
43. Make Of Vehicle*
44. Model
46. Vin Number
47. Year of Vehicle*
49. Color of Vehicle*
51. License Plate Number*
52. License State*
54. Insurance Company*
55. Insurance Phone Number
57. Insurance Policy Number*
58. Insurance Expiration Date
    Insurance Expiration Date
60. Describe Damage and Location of damage to vehicle*
62. Vehicle Owner

    1. Driver
    2. Other Individual
    3. Other Business
64. First Name
65. Last Name
67. Address1
69. City
70. State
71. Zip
73. Phone
75. Confirm Other Vehicles
77. Was there another vehicle involved?*

    1. Yes

    1. No
79. Do you have their information?*

    1. Yes

    1. No
81. Driver Name
    If the vehicle information is not known, please check Unknown
82. Other Vehicle Information

    1. Unknown
84. Address1
86. City
87. State
88. Zip
90. Phone
92. Make of Vehicle
93. Model
95. Vin Number
96. Year
97. Color
99. License Plate Number
100. License State
102. Insurance Company
103. Insurance Phone Number
105. Insurance Policy Number
106. Insurance Expiration Date
     Insurance Expiration Date
108. Where there passengers in the other vehicle?

     1. Yes
     2. No
     3. Unknown
110. First Name
111. Last Name
113. First Name
114. Last Name
116. Do you have their information?

     1. Yes
     2. No
118. Confirm Witness
120. Were there any witnesses?*

     1. Yes

     1. No
122. Do you have their information?*

     1. Yes

     1. No
124. First Name
125. Last Name
127. Address1
129. Phone Number
131. City
132. State
133. Zip
135. First Name
136. Last Name
138. Address1
139. Phone Number
141. City
142. State
143. Zip
145. Property Damaged (other than vehicles)
147. Property Type
149. Owners Name
150. Phone
152. Address1
154. City
155. State
157. Road And Weather Conditions
159. Light Conditions

     1. Daylight
     2. Dawn
     3. Dusk

     1. Dark-Lighted
     2. Dark- Not Lighted
     3. Dark- Unknown Lighting
161. Weather Conditions

     1. Clear
     2. Cloudy
     3. Sleet/Hail (Freezing rain/Drizzle)
     4. Rain
     5. Snow

     1. Severe Crosswinds
     2. Blowing sand, dirt, soil
     3. Fog, Smoke, Smog
     4. Blowing Snow
     5. Other
162. Other
164. Road Surface Conditions

     1. Dry
     2. Wet
     3. Snow
     4. Ice/Frost
     5. Water (standing/moving)

     1. Sand
     2. Mud, Dirt, Gravel
     3. Oil
     4. Other
165. Other
167. Road Grade

     1. Level
     2. Downhill
     3. Uphill

     1. Hill Crest
     2. Sag/Dip/Bottom
     3. Unknown
168. Other
170. Did this occur within an intersection?

     1. Yes

     1. No
172. Direction of Travel

     1. North
     2. South
     3. East
     4. West

     1. Northwest
     2. Northeast
     3. Southwest
     4. Southeast
174. Describe which lane of travel you were in:
176. Please enter a detailed narrative of the incident
178. Attachments
     If you have photos or any other documents you deem important to this case please attach here.
180. Complete!
     Thank you for completing the form. We will have a Traffic Officer assigned to your case and will give you a report number. If you would like to know the status of your case please contact (928) 556-2212. Should you need immediate assistance please contact the Flagstaff Police Department at (928) 774-1414.
Leave This Blank:


182. 1. Receive an email copy of this form.
183. Email address

     This field is not part of the form submission.

184. Submit

* indicates a required field