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______  DRIVER'S REPORT OF TRAFFIC CRASH:  MAIL COPY TO 2900 APALACHEE PARKWAY, TALLAHASSEE, 
FL 32399-0500 ONLY IN INSTANCES WHERE A POLICE REPORT IS NOT COMPLETED.
______ DRIVER EXCHANGE OF INFORMATION: COMPLETE AND EXCHANGE WITH OTHER DRIVER(S).
(NOTE:  DO NOT SEND A COPY OF THIS FORM TO TALLAHASSEE IF THIS IS CHECKED.)

INVESTIGATING AGENCY REPORT NUMBER:
DATE OF CRASH


CITY


COUNTY


ON STREET, ROAD OR HIGHWAY


DRIVER'S NAME


ADDRESS


TELEPHONE


OWNER'S NAME


ADDRESS


TELEPHONE


VEH. YEAR


VEH. MAKE


VEH.TYPE
(CAR,TRUCK,ETC.)


VEH.LICENSE NUMBER


STATE


YEAR


NAME OF MOTOR VEHICLE INSURANCE COMPANY


POLICY NUMBER


WITNESSES OTHER THAN PASSENGERS

NAME

ADDRESS

NAME


ADDRESS


RESPONDING OFFICER
(IF APPLICABLE)


I.D. / BADGE NO.


DEPARTMENT / AGENCY


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