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HomeMy WebLinkAboutUntitled (17) II4p4 Safety Insurance P.0.Box 55098 Boston,MA 02205-5098 1-617-951-0600 Fax (617)345-0896 August 19, 2009 DEROSA, TIANNA M 25 DEVON CT NORTH ANDOVER, MA 01845 Dear Insured, Your vehicle has been appraised and deemed a total loss. Before we can settle your claim, we need you to complete the enclosed paperwork. The settlement process is easy; simply return the completed forms in the enclosed postage-paid envelope. We have also enclosed information about the appraised value of your vehicle. The Actual Cash Value of your vehicle has been provided by CCC Information Services. The final settlement amount can be found in section titled Settlement. To receive your settlement, please complete and return the following: • Bill of Sale & Lienholder Information Release: This document transfers ownership of your vehicle to Safety Insurance. If you have a loan, you need to provide us with the lienholder's information so that we can obtain the title to your vehicle. • Commonwealth of Massachusetts Registry of Motor Vehicles—Assignment and Authorization for Payoff for a Salvage Motor Vehicle: This form gives us the legal authority to obtain the Original Certificate of Title from your lienholder. Per the Massachusetts Registry you are required to complete and sign Part C. • Original Certificate of Title: If you do not have a loan, you are required to provide us with a properly executed Certificate of Title. Please see the enclosed instructions on Completing the Assignment of Certificate of Title by Owner. If you have an outstanding loan, your title may be located with your lienholder. Simply provide us with your lienholder's information and the properly notarized Power of Attorney. We will take care of securing the title from your Lienholder. Commonwealth of Massachusetts - Motor Vehicle ehicle Crash Operator Report When Should You File a Report • You should file a report if you're the operator of a vehicle involved in a crash where the damage to any one vehicle or property is over$1000,or if there is an injury to any person,even if a police officer was on the scene. You should file the report within 5 days of the date of the crash. When Should You NOT File a Report • You should not file a report if the crash occurred on a private road,driveway,private parking lot or other private way. Why this Report is Important Data from this report is used for many purposes including: • Identifying locations with a large number of crashes. • Improving dangerous highways and intersections. • Developing highway safety public information programs. • Developing programs to save lives and reduce highway injuries. How To Complete This Form Please carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegible reports will be returned to you Section A: Crash Location Section F: Crash Conditions • Provide the city/town where the crash occurred, • Use the codes provided to indicate the the date and time of the crash, and the number of conditions at the time of the crash. vehicles involved. • Complete section Al or A2. Section G: Crash Diagram • Use official names of all locations,streets and • Draw a diagram of how the crash occurred. landmarks. • On the diagram,Vehicle 1 represents your • Use street name and route#,if applicable. vehicle. • Be as precise as possible when describing the location. Section H: Witness Information • Provide enough information to locate the crash • List all the people who saw the crash but were to a specific point,not just a street or roadway. not involved. Section B: Vehicle You Were Driving Section I: Property Damage Information • Provide information on your license and the • Indicate all non-vehicular property that was vehicle you were driving. damaged in the crash. • Use the codes provided to indicate the cause of the crash. Section J: Description of What Happened • Describe the crash including events prior to the Section C: You and Your Passengers crash for your vehicles and all other vehicles. • Provide information on you and your passengers at the time of the crash. Section K: Signature • Use the codes provided to indicate occupant • Please sign and print your name and indicate the information. date you completed the form. Section D: Other Vehicles Involved in the Where to send completed reports: Crash • Provide information on the other vehicle(s)and ❑ Mail or deliver one copy to your local police operator(s)involved in the crash. department in the city or town where the crash • If more than one vehicle involved,please use occurred. additional form completing Section D only. ❑ Mail one copy to your Insurance Company. Section E: Non-Motorists) Involved • Provide information on the non-motorist(s) C3 Mail one copy to the RMV at the following address: involved in the crash. Crash Records • If more than one non-motorist involved,please Registry of Motor Vehicles use additional form completing Section E only. P.O.Box 55889 Boston, MA 02205-5889 CRA-23 010365 6003402 05/02 MCI Page 1 Section A: Crash Location City/To Where Crash Occurred _ n Date of Crash e i' rei/e., /�/ J Sy 7 © n : LIFS11— #Vehicles / ! �f(J AM PM Involved: Please complete Section Al or A2 belo4 to indicate the location of the crash. If you need additional space to describe the crash location,please use Section J on the last page of this form. SECTION Al:Complete this Section if the crash SECTION A2: Complete this Section if the crash did NOT occur at an occurred at an intersection of two or more streets OR intersection: Step 1: Please indicate the route or roadway where you Step 1: Please indicate the route, roadway and address where the crash occurred: were travelling when the crash occurred: The crash occurred on Route#: ... at Street or Address Number. Route# on the Street/Roadway known as: Name of Roadway/Street Step 2 What was the name(or names)of the intersecting Step 2: Please provide as much of the following specific location information as possible: streets? The crash occurred(estimate number of feet) 73—cr¢ feet (indicate direction as N/S/E/W) /4/ of Route# Name of Roadway/Street a) Mile Marker number — — —• — OR:b) Exit Number Route# Name of Roadway/Street ORO Intersecting Street/Roadway „�jj(°� Route# Name of Roa way/Street OR:d) Landmark Section B: Vehicle You Were Driving Number of occupants in vehicle(including yourself): Was vehicle damage above$1000? _Yes No IP g a ad2 Q• l e�nse) bcr License,State Dat of Age Sex, License Class Commercial Driver's License Endorsements J r 71'CtiI 41 I3 E D -_—: B _C IH— Hazardous N Tank vehicles P_Passenger Your Full I_ M Unknown T Doubles/rriples X Tanl and Hazardous transport a:111N kfil(Last,• Flue/<os� Street -' ` o��'Xi City/Town tat -Zip L//�� � cS/L �-� s�cs �l �/�si3 Insurance p y V`hr '"gistra%iga 4i. Reg.Type Reg.atate Vehicle Year Vshi cle�� /Make n Indicate your of vehicle • Passenger car 4 Bus(15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other Light truck(van,mini-van, 5 Bus(7-15 passengers) 9 Turk tractor(bobtail) 13 Unknown heavy truck 99 Unknown pick-up,sport utility) 6 Single-unit truck(2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle 3 Motorcycle 7 Single-unit truck(3 or more axles) 11 Tractor/doubles F ,,Fame of Vehicle Owner(Last,First,,pg=d_dle) �S-et—Address City/Town State Zi J I 'la (n L [J --rio5� I daZ 8o�c ;ti LQw��„ce .1C.q- .018-1‘ What Was Your Vehicle Doing Prior to the Crash? Vehicle Travel Direction 1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other N�S_E_W CD Slowing or stopped 5 Changing lanes 8 Making U-turn I 1 Parked 99 Unknown ummg 3 T right 6 traffic lane 9 Overtaking/passing Please Indicate the Sequence of Events as they occurred to YOUR Vehicle by writing the corresponding number (1-52,or 97,99)in up to 4 boxes below. What happened first? What happened 2"(if applicable)? What happened 3" (if applicable)? What happened 4"(if applicable)? / Collision with Non-Collision 1 Motor vehicle in traffic 23 Light pole or other post/support 40 Ran off road right 2 Parked motor vehicle 24 Guardrail 41 Ran off road left 3 Pedestrian 25 Median barrier 42 Cross median/centerline 4 Cyclist 26 Ditch 43 Overturn/rollover 5 'Animal-deer 27 Embankment/Sloping shoulder 44 Equipment failure(blown tire, brakes, etc) 6 Animal- other 28 Highway traffic signpost 45 Fire/explosion 7 Moped 29 Overhead sign support 46 Immersion 8 Work zone maintenance equipment 30 Fence 47 Jackknife 9 Railway vehicle(train,engine) 31 Mailbox 48 Cargo/equipment loss or shift 10 Other movable object 32 Crash cushion/Impact attenuator 49 Separation of units 11 Unknown movable object 33 Bridge 50 Downhill runaway 20 Curb 34 Bridge overhead structure 51 Other non-collision 21 Tree 35 Other fixed object(wall,building,tunnel) 52 Unknown non-collision 22 Utility pole 36 Unknown fixed object 97 Other 99 Unknown ` Vehicle Damaged Area 2 3 O 0 None Was your Vehicle Towed From the Scene Due to Damage?�!Yes _No (circle up to three) 10 Undercarriage I arrirop 11 Other 97 Other 8 7 99 Unknown Page 2 Section C: You and Your Passengers . Please de the full name,address,and DOB or Age for all passengers in your vehicle.Then write the cone (yourself end all passengers). A list of the ssible codes is provided at the bottom of this section. �°n code in each of the boxes for each occupant of the vehicle Date of Sex A B C D E F G H Name of Driver(See previous page) B M� Medical Facility �U�// � -1?-At / / 99 r 0 Name of Passenger 1 (Last,First,Middle) /177 Address t City/Town State 4 Name of Passenger 2 (Last,First,Middle) Address City/Town State Zip Name of Passenger 3 (Last,First,Middle) Address City/Town State Zip A. Seating Position B. Safety System Used C.Air Bag Status D. Air Bag Switch 1 Front seat-left side(or motorcycle driver) 9 Third row-right side 0 None used 1 Deployed-front 1 Switch in ON position 2 Front seat-middle 10 Sleeper section of cab 1 Shoulder and lap belt 2 Deployed-side 2 Switch in OFF position 3 Front seat-right side 11 Enclosed passenger area 2 Lap belt only 3 Deployed both 3 ON-OFF switch not present 4 Second seat-left side(or motorcycle passenger) 12 Unenclosed passenger area 3 Shoulder belt only front and side 4 Unknown if switch is present 5 Second seat-middle 13 Trailing unit 4 Child safety seat 4 Not deployed 99 Unknown 6 Second seat-right side 14 Riding on vehicle exterior 5 Helmet 7 Third row-left side(or motorcycle 5 Not applicable ( y passenger) 97 Other 99 Unknown 99 Unknown 8 Third row-middle 99 Unknown ..k. Ejected From Vehicle?":, Trapped? G. Injured? H. Transported for Medical Care? 0 Not ejected Q Not trapped 1 Fatal injury 1 Not transported 97 Other 1 Totally ejected 1 Freed by mechanical means Non-fatal injury: 2 EMS(emergency service) 99 Unknown 2 Partially ejected 2 Freed by non-mechanical means 2 Incapacitating 5 No injury 3 Police 3 Not applicable 99 Unknown 3 Non-incapacitating 99 Unknown 99 Unknown 4 Possible Section D: Other Vehicle(s) Involved in the Crash , Number of occupants in the Vehicle: Number of injured occupants:_ above$1000 Damage_Yes _N. Moped? Yes_No Hit and Run?_Yes_No k- k„: i 11...t.:. Lien State Date f B• Age Se License Class \(J`, g ��// Commercial Driver's License Encasements Lpq VM_F __D _A B —C H Hazardous N Tank vehicles P Passenger Full Nam f V IL l i� r k — —M—Unknown T= Doubles/Triples s X=Taok and I dour tiaosport q q tehicle Driver(L t Fir 1�tiddle) Str et Address % Ci /Town Zip `i1 1/ corn - ' n 0 /qe0 s/. �V// NI a . c>is�� Company g V"h;cl`t' t gisti 3 Reg.Type Rel.State Vehicle Year Vehicle Make OfYV1 Qy C :0,,,,,,,.. ..-.::,.-,.,..., - / t� a-Oa. �tp� Q i yIndurate type of vehicle t ()1 Passenger car 4 Bus(15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other Light truck(van,mini-van, 5 Bus(7-15 passengers) 9 Truck tractor(bobtail) 13 Unknown heavy truck 99 Unknown pick-up,sport utility) 6 Single-unit truck(2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle 3 Motorcycle 7 Single-unit truck(3 or more axles) 11 Tractor/doubles Full Name of Vehh ie Owner(Last,First,Middle) Street Address City/Town State Zip Vehicle Travel What Was the Vehicle Doing Prior to the Crash? • Vehicle Damaged Area(circle up to three) Direction 2 3 4 0 Nene Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other II 10 Undercarriage _N k S 2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown R 41101161'' 5 11 Totaled —E—W 3 Turning right 6 Entering traffic lane 9 Overtaking/passing 1 7 y 97 Other � 6 99 Unknown Section E: Non-Alotorist(s) Involved in the Crash Indicate the type of non-motorist involved 1 Pedestrian - 2 Cyclist 3 Skater - 97 Other 99 Unknown What was the non-motorist doing prior to the crash? Where was the non-motorist prior to the crash? 1 Entering or crossing location 6 Working on vehicle 1 Marked crosswalk at intersection 6 Median(but not on shoulder) 2 Walking,running, or cycling 7 Standing 2 At intersection but no crosswalk 7 Island 3 Working 97 Other 3 Non-intersection crosswalk 8 Shoulder 4 Pushing vehicle 99 Unknown 4 In roadway 9 Sidewalk 5 Approaching or leaving vehicle 5 Not in roadway 10 Shared-use path or trails 99 Unknown Date of Birth/Age Sex Full Name of Non-Motorist (Last,First,Middle) Street Address City/Town State Zip —M—F Safety Equipment? Injured? Transported for Medical Care? 0 None used 9 Lighting 1 Fatal injury 1 Not transported 97 Other 6 Helmet 10 Other Non-fatal injury: 2 EMS(emergency service), 99 Unknown 7 Protective pads(elbows,knees,etc.) 99.Unknown 2 Incapacitating 5 No injury 3 Police 8 Reflective clothing 3 Non-incapacitating 99 Unknown If transported,please Indicate HospitaVMedical Facility: 4 Possible Page 3