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2. If you need immediate assistance, please call the main number at 860-886-5561 Ext. 6. If this is an emergency, please call 911. If you wish to report activity that is on-going and does not require immediate attention, please complete the form below.
   (Warning: Internet IP addresses are captured when submitting this form. Intentionally completing a form with false information can result in a criminal investigation)
6. Please complete the form below for non-injury or private property accident reports.
8. Date and Time of Accident*
   Date and Time of Accident

   Date and Time of Accident
9. Location of Accident*
13. Unit #1/ Vehicle #1
15. First Name - Operator*
16. Middle Initial
17. Last Name - Operator*
19. Address - Operator*
21. City*
22. State*
23. Zip*
25. Date of birth*
    Date of birth
26. Sex*
    -- Select One --FemaleMale
27. Race*
    -- Select One --AsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslandUnknownWhite
28. Ethnicity*
    -- Select One --Hispanic OriginNot of Hispanic Origin Unknown
30. Drivers License Number*
31. Phone Number*
32. Email Address*
33. Preferred method of communication*

    1. Email
    2. Telephone
35. Were you wearing a seatbelt?*

    1. Yes
    2. No
37. Passengers in the vehicle?*

    1. Yes
    2. No
38. If yes, provide names, DOB and address. Were they wearing a seatbelt?
40. Vehicle #1 Owner (If different than Driver)
42. First Name
43. Middle Initial
44. Last Name
46. Address
48. City
49. State
50. Zip
52. Phone Number
53. Email Address
55. Vehicle #1 Information
57. Year*
58. Make*
59. Model*
60. Color*
62. Plate State and Number*
63. VIN*
65. Insurance Company*
66. Policy Number*
67. Expiration Date*
69. Aditional Information (optional)
73. Unit #2/ Vehicle #2
75. First Name - Operator*
76. Middle Initial
77. Last Name - Operator*
79. Address - Operator*
81. City*
82. State*
83. Zip*
85. Date of Birth*
    Date of Birth
86. Sex*
    -- Select One --FemaleMale
87. Race*
    -- Select One --AsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslandUnknownWhite
88. Ethnicity*
    -- Select One --Hispanic OriginNot of Hispanic Origin Unknown
90. Drivers License Number*
91. Phone Number*
92. Email Address*
94. Were you wearing a seatbelt?*

    1. Yes
    2. No
96. Passengers in the vehicle?*

    1. Yes
    2. No
97. If yes, provide names, DOB and address. Were they wearing a seatbelt?
99. Vehicle #2 Owner (If different than Driver)
101. First Name
102. Middle Initial
103. Last Name
105. Address
107. City
108. State
109. Zip
111. Phone Number
112. Email Address
114. Vehicle #2 Information
116. Year*
117. Make*
118. Model*
119. Color*
121. Plate State and Number*
122. VIN*
124. Insurance Company*
125. Policy Number*
126. Expiration Date*
128. Aditional Information (optional)
130. Images or Supporting Documents*
134. By completing this form, I certify that the information contained herin is true, correct, and complete to the best of my knowledge and belief. I further acknowledge that any intentional false statement or misstatement may be a violation of 53a-180c.
     Please type your name below for the purpose of electronically signing this report (CT Sec. 1-272. Legal recognition of electronic records, electronic signatures and electronic contracts).
136. First and Last name*
137. Date Signed*
     Date Signed
Leave This Blank:


139. 1. Receive an email copy of this form.
140. Email address

     This field is not part of the form submission.

141. Submit

* indicates a required field