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Print all information below: DATE OF CRASH 20 A.M. P.M. PLACE WHERE CRASH OCCURRED: COUNTY CITY OR TOWN STATE If crash was outside city limits of indicate distance from nearest town miles North South East West ROAD ON WHICH CRASH OCCURRED Year Make Type (Sedan, truck, taxi, etc.) Year Make Type (Sedan, truck, taxi, etc.) VEHICLE VEHICLE LICENSE PLATE LICENSE PLATE DRIVER DRIVER DRIVER'S DRIVER'S ADDRESS ADDRESS DATE OF BIRTH DATE OF BIRTH DRIVER'S DRIVER'S LICENSE LICENSE OWNER OWNER OWNER'S OWNER'S ADDRESS ADDRESS INSURANCE CARRIER INSURANCE CARRIER VEHICLE DAMAGE VEHICLE DAMAGE VEH DAMAGE OVER $1000.00 Yes NO VEH DAMAGE OVER $1000.00 Yes NO DAMAGE TO PROPERTY DAMAGE TO PROPERTY OTHER THAN VEHICLE OTHER THAN VEHICLE Name and address of owner of object struck WAS THERE AN Yes Department OFFICER AT THE SCENE No Name or badge number NAME Driver Front Seat Passenger Back Seat Passenger 1. Visible injuries. Pedestrian 2. Complaint of pain, without visible signs of injury. Driver NAME Front Seat Passenger 1. Visible injuries. Back Seat Passenger 2. Complaint of pain, without visible signs of injury. Pedestrian WEATHER Clear Raining Snowing Fog Specify Other ROAD SURFACE Dry Wet Muddy Snowy Icy LIGHT Daylight Dusk Dawn Darkness-street lighted Darkness - street not lighted Indicate North By Arrow SIGN HERE HQ 1598 Signature Of Person Involved Date CRASH DIAGRAM DESCRIBE WHAT HAPPENED In Vehicle No. In Vehicle No. INJURED PERSONS SEATING POSITION OF INJURED Check One City, County, State Street City and State Zip Code Number State First Name Middle or Maiden Name Last Name City and State Zip Code Month Day Year First Name Middle or Maiden Name Last Name Street or R.F. D. Street City and State Zip Code Number State First Name Middle or Maiden Name Last Name City and State Zip Code Month Day Year First Name Middle or Maiden Name Last Name Street or R.F. D. Give name or street or highway number (U.S. or State) AT IT'S INTERSECTION WITH YOUR VEHICLE - NO 1 OTHER VEHICLE - NO 2 (City or Town) HOUR DAY OF WEEK Year State Number Year State Number such crash within ten days in writing to the department at this address: Montana Highway Patrol - 2550 Prospect Ave - Helena, MT 59620 If the investigating officer or agency does not produce a written report and the damage is in excess of $1000.00 the operator of the vehicle must report MONTANA HIGHWAY PATROL VEHICLE CRASH REPORT shall immediately by the quickest means of communication give notice of such crash to the local law enforcement agency. The driver of vehicle involved in a crash resulting in injury to or death of any person or property damage to an apparent extent of $500.00 or more Male Female Male Female