STATE OF WYOMING - INVESTIGATOR'S TRAFFIC ACCIDENT REPORT

PR-802 Rev. 4-91

SHEET 1

STATE OF WYOMING - INVESTIGATOR'S TRAFFIC ACCIDENT REPORT

OF 2

CASE NO 0705200501

ON PRIVATE DATE OF ACCIDENT

TIME (24 hr)

DAY OF WEEK NUMBER PERSONS NUMBER NUMBER NUMBER INVESTIGATED HIT/RUN PHOTOS

PROPERTY?

1

YES NO 7/5/2005

1715

2

7/5/2005 PUBLIC PROPERTY NOTIFIED

DAMAGE?

POLICE DATE

TIME

2

YES

NO ARRIVED

7/5/2005

TU

1725 1740

VEHICLES INVOLVED

2

5

NOTIFIED: EMS DATE

ARRIVED:

OF PEDS

0

INJURED

2

TIME

KILLED

AT SCENE

YES

0

YES

NO

NO

POLICE NOTIFIED BY

Driver Veh1

EMS RADIO NUMBER

YES NO

32

-

-

LOCATION OF ACCIDENT

COUNTY

CITY

33

3

Laramie

Cheyenne

-

- ACCIDENT OCCURED ON: name of street, road, or highway number

AT INTERSECTION WITH:

34

4 HWY 80 1 5 IF NOT AT

INTERSECTION

FEET MILES

DIRECTION

W OF HWY 25

nearest street, highway, ramp, bridge, city, railroad crossing, etc.

2

35

5

HIGHWAY

HIGHWAY

IF AT

Identify ramp (accel or decel), crossroad, etc.

MILEPOST

1 MARKER:

SECTION NUMBER:

INTERCHANGE LOCATION:

-

VEHICLE 1

VEHICLE 2

36

DRIVER NO. 1 LAST NAME

6

Manning 1 ADDRESS

FIRST

Trevor

MIDDLE INITIAL DRIVER NO. 2 LAST NAME

E

SOCIAL SECURITY NUMBER

McCrae

ADDRESS

FIRST

Mellissa

- MIDDLE INITIAL

K

37 SOCIAL SECURITY NUMBER

7 535 York Ave

548-46-8415

89-322 Street

137-84-6853

-

1 CITY Cheyenne

8

DRIVER'S LICENSE NO.

1 8230932

OCCUPATION

Programmer

STATE

ZIP

WY 82003

CLASS

M

EMPLOYED BY

Visual Statement

PHONE

CITY

3 0 7 1 3 5 4 6 2 3 Cheyenne

STATE

DATE OF BIRTH DRIVER'S LICENSE NO.

WY 12/21/1982 3579545

BUSINESS PHONE

OCCUPATION

3 0 7 1 8 6 4 1 3 4 Sales

STATE

ZIP

WY 82004

CLASS

M

EMPLOYED BY

Smith Chevrolette

PHONE

3 0 7 9 8 4 3 1 6 8 38

STATE

DATE OF BIRTH

-

WY 8/2/1964

BUSINESS PHONE

39

3071684635 -

9

MALE

POSTED

50 FEMALE SPEED

2 CARRIER'S NAME

2 NUMBER OF

OCCUPANTS

55 EST.

INSURANCE CO.

SPEED State Farm

VEHICLE SIDE

GVWR:

NO. AXLES

MALE

POSTED

50 FEMALE SPEED

CARRIER'S NAME

3 NUMBER OF

OCCUPANTS

EST. 65

SPEED

INSURANCE CO.

All State

40

VEHICLE SIDE

GVWR:

19 NO. AXLES

10

CARRIER'S IDENTIFICATION

1

SHIPPING PAPERS

DRIVER

US DOT HAZ MAT PLACARD?

ICC MC

YES

NO

NUMBER/NAME

.

HAZ MAT RELEASE?

CARRIER'S IDENTIFICATION

YES NO

SHIPPING PAPERS

DRIVER

US DOT ICC MC

HAZ MAT PLACARD?

YES

NO

NUMBER/NAME

.

41

HAZ MAT

19 RELEASE?

YES NO

VEHICLE OWNER LAST NAME

11

Manning

same as driver

7 ADDRESS

535 York Ave

12 VEHICLE IDENTIFICATION NO.

FIRST

Trevor

CITY

Cheyenne

LICENSE NO.

MIDDLE INITIAL

E

STATE

VEHICLE OWNER LAST NAME

McCrae

same as driver ADDRESS

WY 89-322 Street

YEAR STATE VEHICLE IDENTIFICATION NO.

FIRST

Mellissa

CITY

Cheyenne

LICENSE NO.

MIDDLE INITIAL 42

K 1

STATE

WY 43 3 YEAR STATE

1 415648485654

MAKE

13 Ford

MODEL

Mustang

BODY STYLE

Coupe

8472WT

YEAR COLOR

0 2 Grey

0 5 WY 431514654354

ODOMETER

MAKE

25481 Honda

MODEL

Civic

BODY STYLE

Sedan

9583MK

YEAR COLOR

9 8 Green

0 5 WY 44

ODOMETER

50713

2

1

SHADE DAMAGED AREAS

CHECK APPROPRIATE BOX IF APPLICABLE

1 HEAD ON

2 REAR END

3 ANGLE

4 SIDESWIPE

5 SIDESWIPE

COLLISION

MEETING

PASSING

14

6 OVERTURN

7 INVOLVED

8 INVOLVED

9 INVOLVED RIGHT

10 OTHER

1

LEFT TURN

RIGHT TURN

TURN ON RED LIGHT

DIAGRAM

SHADE DAMAGED AREAS 45

2

46

15

1

1

47

-

INDICATE INITIAL IMPACT BY ARROW

VEHICLE TOWED BY: 17

VEHICLE TOWED TO:

1

18 ESTIMATED REPAIR COST

$ 1500

1 TICKET/

DRIVER NO. 1

ARREST 19

DRIVER NO. 2

ACCIDENT

3 DESCRIPTION

20

PEDESTRIAN OTHER

TICKET NO. 4681893 VIOLATION SECTION Following Too Close

INDICATE INITIAL IMPACT

48

BY ARROW

VEHICLE TOWED BY:

3

Mikes Auto Towing

VEHICLE TOWED TO:

49

Buzz's Auto Body

ESTIMATED REPAIR COST

3

4500 use PR 803 for additional space $

REQUEST

DRIVER NO.

LICENSE

INVESTIGATION

1

Witnesses

21 22 23 24

25

11 3 4 1

22 4 3 1

32 6 3 1

26

27 28 29 30 31

19 F 1 7 Johnson

12 M 4 6 McCrae

10 F 5 6 McCrae

ALL PERSONS INVOLVED

Lisa

E 837 McGill Rd

Cheyenne

Jeff

K 89-322 Street

Cheyenne

Lee

K 89-322 Street

Cheyenne

31 50 51

WY 82003 1 WY 82004 1 WY 82004 1

4

5

6

7

8

SIGN HERE:

OFFICER'S RANK & NAME

Bob Smith

BADGE NO.

c99

DEPARTMENT

Cheyenne Police Department

DATE OF REPORT

7/7/2005

DIVISION

J

AGENCY USE

ACCIDENT RECORDS & FINANCIAL RESPONSIBILITY WYOMING DEPARTMENT OF TRANSPORTATION

PR-803 Rev 1-86

SHEET 2 OF 2

DATE OF ACCIDENT

7/5/2005

DRIVER NO. 1

Trevor Manning

STATE OF WYOMING

INVESTIGATOR'S SUPPLEMENTAL TRAFFIC ACCIDENT REPORT

DIAGRAM/NARRATIVE

CASE NO 0705200501

COUNTY

LOCATION

Laramie

HWY 80

DRIVER NO. 2

Mellissa McCrae

ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED

SCALE:

Veh1 was traveling East bound on the highway when a deer began to cross the roadway. Veh1 began slowing so avoid hitting the deer. Veh2 was following too closely to Veh2 and was approximately 15MPH over the speed limit. Veh2 couldnt stop in time and rear ended Veh1 pushing Veh1 into the middle of the road and itself into the center median.

OFFICER'S NAME & RANK

BADGE NO.

DEPARTMENT

DATE OF REPORT

PATROL DIVISION

Bob Smith

c99

Cheyenne Police Department

7/7/2005

J

ACCIDENT RECORDS & FINANCIAL RESPONSIBILITY WYOMING DEPARTMENT OF TRANSPORTATION

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