Commonwealth of Massachusetts
Number
Motor Vehicle Crash Vehicles
1
Police Report
Police Use Only
Date of Crash Time of Crash
02/14/2017
NEWTON
15:27
24HR
<
AT INTERSECTION:
1
1
2
1
3
LOCATION
1 Occupants
X Hit/Run
X Vehicle 1 ___#
‰
‰
‰ Moped
F
Sex____
Lic. Class D
18
18
Lic. Restrictions
1
19
CDL ________
Endorsment
5
1
1
NOT AT INTERSECTION:
AUDI
2017
Veh Year______________
Veh Make______________________
Veh Config.
MA Zip ___________
BOSTON
02113
City _________________________________
State______
City ___________________________________________ State______ Zip ___________
GEICO
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Vehicle Travel Direction:
N S X
E W
Responding to Emergency?____
Last
Event Sequence
First
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
25
Age/DOB
See Above
Please Select One
of the Following:
‰ Vehicle
___# Occupants
‰ Non-Motorist A
License # __________________________ St ______ DOB/Age __________
18
18
Sex____ Lic. Class
8
1
14
3
4
1
9
10 Undercarriage
5 11 Totaled
8
O
7
O
24
Towed ____
27
- - - - - - 99
15
Action
22
2
28
29
30
31
32
33
99
4
16
Location
0
0
5
17
Condition
‰ Hit/Run ‰Moped
Reg # _____________________________ Reg Type____________ Reg State__________
20
19
Lic. Restrictions
CDL ________
Veh Year______________ Veh Make______________________ Veh Config.
Endorsment
Operator ______________________________________________________
Last
First
Owner __________________________________________________________________
Middle
Last
First
Middle
Address _______________________________________________________
Address _________________________________________________________________
City _________________________________ State______ Zip ___________
City ___________________________________________ State______ Zip ___________
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Vehicle Travel Direction:
N S E W
Responding to Emergency?____
Citation # (If Issued)______________
Event Sequence
22
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
See Above
--------
3
4
1
9
10 Undercarriage
5 11 Totaled
8
7
6
Towed ____
26
Age/DOB
22
Sex
24
24
25
Please fill out for operator and all occupants involved
Operator/Non-Motorist
22
Damaged Area Code: (Circle Up to Three)
2
23
Most Harmful Event
Address
21
22
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Name (Last First Middle)
5
11
27
28
29
30
31
32
33
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
--- ---
1
12
6
O
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
Medical Facility
Sex
--------
Type
10
Damaged Area Code: (Circle Up to Three)
24
1
26
Address
21
Middle
23
1
Please fill out for operator and all occupants involved
1
1
22
22
22
1
Most Harmful Event
Operator
2
20
Address _________________________________________________________________
Middle
Name (Last First Middle)
7
1
158 ENDICOTT ST (apt. 2)
Address _______________________________________________________
First
9
7YBN40
PAN
MA
Reg # _____________________________
Reg Type____________
Reg State__________
(Same as operator)
Owner __________________________________________________________________
Last
2
1700000203
DIRMARZIO
DANA
Operator ______________________________________________________
Citation # (If Issued)______________
6
>
Case Number
MA
1
State Police ‰
Local Police X
‰
MBTA Police ‰
Other:
Number Speed Limit
Injured Latitude
Longitude
0
PAUL ST
EAST
6
______ ________
_____________________________________________________ _____ _________ __________ ___________________________________________
Route# Direction
Name of Roadway/Street
Route#
Direction Address #
Name of Roadway/Street
_________________________________________________________________________
__________________________________________________________________________
At
___ ___ ___ z ___ or __________________
________Feet N S E W of
______ ________
_____________________________________________________
Mile Marker
Exit Number
Route# Direction
Name of Intersecting Roadway/Street
_________________________________________________________________________
________Feet N S E W of
Also at Intersection with
_______ _______________________________
Route#
Intersecting Roadway/Street
________Feet N S E W of
______ ________
_____________________________________________________
___________________________________________
Route# Direction
Name of Intersecting Roadway/Street
Landmark
S48932385
-/--/-- License # __________________________
St _____ DOB/Age ___________
4
RMV Document Number
City/Town
Medical Facility
1
13
= Direction
ie:
Crash Diagram:
1
= Vehicle 1
1
2
=Vehicle 2
= Pedestrian
2
If Crash Did Not Occur
on a Public Way:
ˆ Off-Street Parking Lot
ˆ Garage
ˆ Mall/Shopping Center
ˆ Other Private Way
Indicate North by Arrow
Crash Narrative:
__________________________________________________________________________________________________________________________________________________
OPERATOR 1 OF MV 1 WAS TRAVELING EB ON PAUL ST WHEN AN UNK MV (BLACK SUV) SPED UP AND DUE TO THE SNOW
__________________________________________________________________________________________________________________________________________________
MAKING THE STREET NARROW THE UNK MV HIT THE DRIVERS SIDE
OF MV 1. THE OTHER VEHICLE LEFT THE SCENE TRAVELING
__________________________________________________________________________________________________________________________________________________
ON CENTER ST IN AN UNK DIRECTION. NO INJURIES TO THE OPERATOR AND MINOR DAMAGE TO MV1.
__________________________________________________________________________________________________________________________________________________
I CHECKED THE SURROUNDING AREA WITH NEGATIVE RESULTS FOR THE MV.
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
W itnesses:
Name (Last, First, Middle)
Address
Phone #
Statement
Property Damage:
Owner (Last, First, Middle)
Address
Truck and Bus Information:
Phone #
34-Type
Description of Damaged Property
Registration # ___________________________(From Vehicle Section)
35
Carrier Name ___________________________________________________________________________________________ Carrier Issuing Authority Code
Address___________________________________________________________ City________________________________
St________
Zip___________
US DOT #: ______________________ State Number________________________ Issuing State ________ ICC #:_____________________ Interstate
Cargo Body Type Code
37
36
38
Gross Vehicle Weight
39
Trailer Reg #:_______________________ Reg Type__________ Reg State _________ Reg Year__________ Trailer Length
Hazmat Information:
Placard
40
Material 1 digit #
41
Material Name______________________________ Material 4 digit # _____________ Release code
42
ROBERT A MARCH
02/14/2017
_________________________________________________________________________________________________________________________________________________
Police Officer Name (Please Print)
Signature
ID/Badge #
Department
Precinct/Barracks
Date
NEWTON POLICE DEPARTM
CDP1 11 . 24. 00