Atlanta Personal Injury Law Group - Gore

Accident Number 1703 Agency NCIC No. County COBB Date Rec. by DOT GEORGIA UNIFORM MOTOR VEHICLE ACCIDENT REPORT Day Of Week SATURDAY Injuries Fatalities 1 Date Vehicles 2 Inside City Of: Time 21:50 Off. Arrived Hit And Run? 22:10 Suppl. To Original? AT FAULT PARTY’S NAME Road of Occurence WOODSTOCK PP 100 Feet From its ersection With MABRY RD West Private Proporty Last Name First Middle Last Name First Middle UNIT 1- DRIVER Address Address City CUMMING State GA City KENNESAW State Zip 30144 DOB Zip 30040 DOB GA State Driver's License No Class CLASS C State GA VMale OFemale Driver's License No OMale VFemale CLASS C GA AT FAULT PARTY’S INSURANCE & POLICY NUMBER Posted 45 Policy No. Insurance Co. Policy No. Insurance Co. Posted 45 Speed STATE FARM MUTUAL AUTOMOBILEI Year 1997 Model CRV Year 2010 Model WRANGLER SAH Telephone No. Telephone No. Make HONDA JEEP VIN Vehicle Color VIN Vehicle Color Other Other Tag # State County Year Tag # State County Year GA FORSYTH 2017 GA СОВВ 2016 Trailer Trailer VEHICLE OWNER NAME Owner's Last Name First Middle Same as Owner's Last Name First Middle Same as Driver "Driver Address Address City KENNESAW City State Zip State Zip CUMMING GA 30041 GA 30144 Removed By Removed By MAETTA WRECKER Alcohol Test ORequest OList ORequest OList MARIETTA WRECKER Dua Test Drug Test No Results Mcohol Test Results Tune Not Tested Results Туре Not Tested Туре Results Туре No None Given No None Given No Dver Cond Not Drinking Vision Obscured Contributing raetors No Contributing Factors Direction of Tra Vision Obscur d Contributing Factors river Cond Following too Close TOW TRUCK COMPANY WHO MOVED CAR Direction of Travel Not Obscured Ninking Not Obscured Vehicle Cond Vehicle Maneuver Straight Pea euver Vehicle Coc Vehicle Maneuver Ped Maneuver No Known Defects No Known Defects Stopped Vehicle Type: ity Passenger Vehic Vehicle Type: Utility Passenger Vehicle Most Harmful Event Vehicle Class Most Harmful Event Yahicle Class Motor Vehicle In Motion Privately Owned Motor Vehicle In Motion Privateryned Traffic Ctrl Lanes Device Inoperative? OYes Traffic Ctrl Lanes Device Inoperau Yes ]No Injured Taken To : By: Injured Taken To : EMS Notified Time EMS Arrival Time EMS Ntified Time EMS Arrival Time Hospital Arrival Tim Photos Taken Hospital Arrival Time Photos OYes VNo By: OYes VNo By: CONTRIBUTING FACTORS Taken Commercial Vehicles Only Com cial Vehicles Only Carrier Name Carrier Name Vehicle # 1 Vehicle # Address City State Zip Address City State Zip No. of Axles No, of Axles Fed. Reportable OYes VNo Carge Body Type G.V.W.R Fed. Reportable OYes VNo Cargo Body Type G.V.W.R Vehicle Config. I.C.C.M.C. # U.S. D.O.T. # Interstate Vehicle Config. U.S. D.O.T. # Interstate I.C.C.M.C. # Intrastate Intrastate DUI TEST GIVEN & RESULTS C.D.L. ? C.D.L. Suspended? OYes No Hazardous Materials? Yes ONo Yes Yes OYes If YES, Name or 4 Digit Number from Diamond Yes C.D.L. ? Yes No C.D.L. Suspended? Hazardous Materials? Yes ONo No No Vehicle Placarded ? Yes No Vehicle Placarded ? No OYes If YES, Name or 4 Digit Number from Diamond Released ? ONo ONo Released ? ORan Off Road ODown Hill Runaway OCargo Loss or Shift Separation of Units ORan Off Road ODown Hill Runaway OCargo Loss or Shift Separation of Units Officer Information Report By: Badge # Department Report Date Submitted By Checked By Date Checked WITNESS INFO WISE 1352 POLICE 4/23/2017 11:21:20 PM COBB CO PD TRANS STYMUS 4/23/2017 1:28:00 AM CIIACA nD Witnesses None Listed Guide to Reading Police Reports 0000 ATLANTA PERSONAL INJURY CROUP LAW