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Get CA STD. 268 2007

ACCIDENT REPORT Other than Motor Vehicle STD. 268 REV. 11/2007 Page 1 of 2 CONFIDENTIAL ATTORNEY/CLIENT PRIVILEGED DOCUMENT/WORK PRODUCT This is a CONFIDENTIAL report requested by prepared for and retained by the Attorney General s Office. Clear Print STATE OF CALIFORNIA This report shall be completed and forwarded to the Attorney General s Office within 48 hours of the incident. Attach any photos or diagrams. Reports of serious injuries and/or death shall be reported to the Attorney General s Office within 24 hours of the incident. Under no circumstances should this document be provided to anyone except the Attorney General s Office or their agent. LOCATION Describe specific location on reverse INCIDENT DATE TIME INJURED PARTY INFORMATION BIRTHDATE DRIVER S LICENSE NUMBER INJURED PARTY S MAILING ADDRESS Street City State Zip HOME TELEPHONE Area Code No* WORK TELEPHONE Area Code No* NATURE AND EXTENT OF APPARENT / CLAIMED INJURY Describe incident in detail on reverse PHOTOGRAPHS TAKEN YES FIRST AID GIVEN IF YES BY WHOM NO PROPERTY DAMAGE/LOSS INFORMATION PROPERTY OWNER S NAME Last First M. I. WITNESS INFORMATION 1. NAME Last First M. I. WORK ADDRESS Street City State Zip HOME Street City State Zip REPORTING AGENCY NAME REPORTING EMPLOYEE S NAME AND TITLE Print or Type TELEPHONE NUMBER Area Code No* DISTRIBUTION ORIGINAL--ATTORNEY GENERAL S OFFICE TORT UNIT P. O. BOX 944255 SACRAMENTO CA 94244-2550 WITHIN 48 HOURS* COPY--RETAINED BY THE LEGAL OFFICE OF THE REPORTING AGENCY/DEPARTMENT. USE ADDITIONAL SHEETS AS NECESSARY DESCRIBE SPECIFIC LOCATION OF INCIDENT DESCRIBE THE INCIDENT IN DETAIL. Clear Print STATE OF CALIFORNIA This report shall be completed and forwarded to the Attorney General s Office within 48 hours of the incident. Attach any photos or diagrams. Reports of serious injuries and/or death shall be reported to the Attorney General s Office within 24 hours of the incident. Under no circumstances should this document be provided to anyone except the Attorney General s Office or their agent. LOCATION Describe specific location on reverse INCIDENT DATE TIME INJURED PARTY INFORMATION BIRTHDATE DRIVER S LICENSE NUMBER INJURED PARTY S MAILING ADDRESS Street City State Zip HOME TELEPHONE Area Code No* WORK TELEPHONE Area Code No* NATURE AND EXTENT OF APPARENT / CLAIMED INJURY Describe incident in detail on reverse PHOTOGRAPHS TAKEN YES FIRST AID GIVEN IF YES BY WHOM NO PROPERTY DAMAGE/LOSS INFORMATION PROPERTY OWNER S NAME Last First M. LOCATION Describe specific location on reverse INCIDENT DATE TIME INJURED PARTY INFORMATION BIRTHDATE DRIVER S LICENSE NUMBER INJURED PARTY S MAILING ADDRESS Street City State Zip HOME TELEPHONE Area Code No* WORK TELEPHONE Area Code No* NATURE AND EXTENT OF APPARENT / CLAIMED INJURY Describe incident in detail on reverse PHOTOGRAPHS TAKEN YES FIRST AID GIVEN IF YES BY WHOM NO PROPERTY DAMAGE/LOSS INFORMATION PROPERTY OWNER S NAME Last First M. I. WITNESS INFORMATION 1. NAME Last First M. I. WORK ADDRESS Street City State Zip HOME Street City State Zip REPORTING AGENCY NAME REPORTING EMPLOYEE S NAME AND TITLE Print or Type TELEPHONE NUMBER Area Code No* DISTRIBUTION ORIGINAL--ATTORNEY GENERAL S OFFICE TORT UNIT P. .

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