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Reporting requirements
Did any person involved in the crash get transported from the
scene by ambulance to receive medical treatment? (Mandatory)
Yes
Did the police complete an official report regarding this crash? (Mandatory)
No
Yes
i
No
Unsure
Date (Mandatory)
Thursday
24/09/2015
Time (Mandatory)
1.00
dd/mm/yyyy
am/pm (Mandatory)
hh.mm
pm
e.g. 07.38pm
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Yes
No
Yes
No
Vehicle information
Vehicle 1 is the vehicle you were driving. If you were a pedestrian in the crash then vehicle 1 is
the vehicle that hit you or came closest to hitting you. If there were other vehicles in the crash
please provide details about them by clicking the add vehicle button at the bottom of this step.
Number of vehicles
2
1
Type of vehicle (Mandatory)
Taxi or hired car
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Vehicle Details
State of current vehicle registration (Mandatory)
ACT
Vehicle registration number (Mandatory)
412
Registration expiry date
dd/mm/yyyy
Make
Ford
e.g. Ford
Model
Falcon
e.g. Falcon
Colour
Year of manufacture
White
2007
e.g. 2001
No
dd/mm/yyyy
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If the drivers licence shows more than one class, please enter the class that applies to the vehicle involved
in this crash.
Licence vehicle class (for vehicle involved in crash)
(Mandatory)
Car (motor vehicle up to 4.5 tonnes)
Licence class type (for vehicle involved in crash)
(Mandatory)
Full
Does the driver have another class on their licence?
No
Driver Details
Gender (Mandatory)
Male
Date of birth (Mandatory)
01/07/1993
dd/mm/yyyy
Full name
Arif Uddin
Address
1/31, Marshall St, Farrer
Phone number
0470248136
Did the driver sustain injuries that required
any attention at the crash site? (Mandatory)
No
Was driver wearing a seatbelt
Belt worn
Passenger Details
Were there any passengers in/on this vehicle (Mandatory)
No
2
Type of vehicle (Mandatory)
Unknown
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Did the driver of this vehicle fail to stop to provide their details to the other
parties involved? (Mandatory)
No
Vehicle Details
State of current vehicle registration
ACT
Vehicle registration number
YHH77T
Registration expiry date
dd/mm/yyyy
Make
Volkswagen
e.g. Ford
Model
e.g. Falcon
Colour
Year of manufacture
e.g. 2001
Black
Damage to the vehicle
Minor damage
Damage details
Side door scratched on left side.
No
dd/mm/yyyy
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If the drivers licence shows more than one class, please enter the class that applies to the vehicle involved
in this crash.
Driver Details
Gender
Female
Date of birth
31/08/1977
dd/mm/yyyy
Full name
Kim Mallett
Address
18 Swinney St, Casey, ACT 2913
Phone number
0420946836
Did the driver sustain injuries that required
any attention at the crash site?
No
Was driver wearing a seatbelt
Unknown
Passenger Details
Were there any passengers in/on this vehicle
No
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Crash Conditions
Please select one option from the 22 below that best describes the collision (Mandatory)
Vehicle to vehicle collision
Struck pedestrian
Struck pedestrian
Struck animal
Struck vehicle
Struck object
Struck animal
Overturned
Struck object
Head on collision
Overturned
Other collision
No object struck
Other collision
U-turn
Movement of vehicle (Mandatory)
Straight ahead
Please use the map at step 2 to aid in determining each vehicle's direction.
North is at the top of the map.
Direction of vehicle (Mandatory)
1
South West
Direction of vehicle (Mandatory)
South
Vehicle position (Mandatory)
Shoulder
Vehicle action
Proceeding normally
Vehicle action
Out of control
Vehicle headlights
Not applicable
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Vehicle headlights
2
Not applicable
Visibility restrictions (Mandatory)
Not obstructed
Visibility restrictions (Mandatory)
Unknown
Yes
No
Yes
No
Witness information
Did anybody witness the crash? (Mandatory)
Yes
No
Declaration
Full name (Mandatory)
Arif Uddin
Address (Mandatory)
1/31, Marshall St, Farrer
I declare that I was one of the drivers/pedestrians or a representative of one of the drivers/pedestrians
involved in the crash detailed in this report, and I declare that the information that I have supplied in
this report is true and correct and complete to the best of my ability. (Mandatory)
Submit
Send me a copy of this completed form via email?
Please enter your email address below and then confirm it is correct by entering it again. The 2 addresses
must match in order for us to email you a copy of this form.
Email address (Mandatory)
arif.uddin@live.com.au
Confirm Email address (Mandatory)
arif.uddin@live.com.au
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Submission Acknowledgement
Your form has been successfully submitted. Please keep a copy of this acknowledgement for your records.
In most cases the AFP will NOT need to contact you regarding your report. Please retain a copy for your
records and if necessary, provide the form submission ID to your insurer.
Please note, it is not possible to amend the information in the crash report once it has been submitted. If
you require a correction for insurance purposes, you could contact your insurance company directly or
alternatively, submit a new crash report and make reference to your original report in the Comments.
If your insurance company requires a copy of the other partys crash report, you can request their report
from the ACT Police here: http://www.police.act.gov.au/contact/request-for-act-policing-reports.aspx.
Date and time.24 Sep 2015 16:26:26
Form submission ID. 99102120150924164555
To save or print a copy of the completed form and acknowledgement go to the "File" menu and select
"Save as" or "Print".
13
24 Sep 2015
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