D

CONNECTICUT UNIFORM POLICE ACCIDENT REPORT
GPS READINGS: Latitude: Time:

FORM PR-1 REV.01/01

R A

04 1 1 1 1 8 3 2 02 1 01

00:00

Longitude:
ACCIDENT SEVERITY Fatal Injury X PDO # VEHICLES INVOLVED PAGE #

B

FOR DOT USE ONLY
POLICE CASE NUMBER
C D E F G

DATE OF ACCIDENT MILITARY TIME

0 1 1 7 1 3 1 7 5 6
TOWN OR CITY NAME

2

1 of 4
(Street Name or Route #)

A 1300000856
(Street Name or Route #)

TOWN CODE ACCIDENT OCCURRED ON

East Haven
IF NOT AT INTERSECTION 1. MEASURE DISTANCE (Check Appropriate Boxes)

AT ITS INTERSECTION WITH at

0 4 4
Feet Tenths Meters Kilometers Pedestrian 2. DIRECTION North South East of West

Sargent Drive

Interstate 95 South Entrance Ramp

3. NAME OF NEAREST INTERSECTING STREET, TOWN LINE OR MILE MARKER

02 1 01

H 1 S 1 T 1

Accident Occurred: TRAFFIC UNIT # 2

On Private Property Pedestrian

Parking Lot

TRAFFIC UNIT # 1 OPERATOR # 1

H 2 S 2 T 2

X Vehicle

Non-Contact Vehicle (Last, First, Middle Initial) PROPER LICENSE CLASS Yes

X Vehicle

Non-Contact Vehicle (Last, First, Middle Initial) PROPER LICENSE CLASS

or PEDESTRIAN NAME

OPERATOR # 2

or PEDESTRIAN NAME

Cash, Dominique
ADDRESS (Street Number and Name)

Bissette, Kershen
ADDRESS (Street Number and Name)

J 11 J 12

1331 Chapel St Apt. #: B
CITY OR TOWN STATE

X No
SEX M
Day

471 North High St
CITY OR TOWN STATE

X Yes
ZIP CODE

No SEX

J 21

ZIP CODE

New Haven
OPERATOR LICENSE #

CT
STATE

06511 CT
Month

X F
Year

East Haven
OPERATOR LICENSE #

CT

06512
STATE

X M
Day

F
Year

J 22

DATE OF BIRTH

237814796
U 1 K 11 K 12

1 1 2 8 8 4

148376546 Town of East Haven
ADDRESS (Street Number and Name)

CT

Month

DATE OF BIRTH

0 2 1 3 8 8
U 2 K 21

OWNER'S NAME (Enter SAME if Owner is Operator)

Deming, Jennifer
ADDRESS (Street Number and Name)

OWNER'S NAME (Enter SAME if Owner is Operator)

84 Jackson Ln
CITY OR TOWN STATE ZIP CODE BODY TYPE

250 Main St CT
STATE VEHICLE YEAR AND MAKE

New Haven
REGISTRATION #

4d Sed Nissan 3 C 2 1 5 2 2 5

CITY OR TOWN

STATE

ZIP CODE

BODY TYPE

K 22 V

East Haven 103EHA 2 F

CT CT 2012

06512 Ford 1

4-DR 1 26
W

REGISTRATION #

STATE VEHICLE YEAR AND MAKE

556ZRM 1 N 4 A L

CT

2003

VEHICLE IDENTIFICATION NUMBER

VEHICLE IDENTIFICATION NUMBER

1 1 D 7

A B P 7 B V X B X 1 8

0 5 7

CARRIER NAME CARRIER ADDRESS (#, Street, City or Town, State, Zip Code) SOURCE OF CARRIER NAME USDOT # Shipping Papers/Trip Manifest ICCMC # Driver Side of Vehicle GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACARD No 4 Digit # REQUIRED? Yes RATING # No 1 Digit # DISPLAYED? Yes

CARRIER NAME CARRIER ADDRESS (#, Street, City or Town, State, Zip Code) SOURCE OF CARRIER NAME USDOT # Shipping Papers/Trip Manifest ICCMC # Driver Side of Vehicle GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACARD No 4 Digit # REQUIRED? Yes RATING # No 1 Digit # DISPLAYED? Yes

X 1 Y 1 Z 1

}

}

X 2 Y 2

HAZARDOUS CARGO RELEASED? Yes

None ENFORCEMENT ACTION TAKEN No X Arrest Verbal Warning Written Warning SUBJECT X Operator OF Owner ACTION Carrier Pedestrian

None Z HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN 2 RELEASED? Yes No Arrest Verbal Warning Written Warning STATUTE OR ORDINANCE #'S SUBJECT OF ACTION Operator Owner Carrier Pedestrian
AA 21 AA 22 AA 23

STATUTE OR ORDINANCE #'S

14-213b, 14-36(a)
AA 11 AA 12 AA 13 AA 14

AUTOMOBILE INSURANCE -- NAME -- POLICY #

AUTOMOBILE INSURANCE -- NAME -- POLICY #

None NONE
PARTS OF VEHICLE DAMAGED

SELF INSURED N/A
PARTS OF VEHICLE DAMAGED

Left Front
VEHICLE TOWED TO: TOWED DUE TO DAMAGE

Right Rear Door
VEHICLE TOWED TO: TOWED DUE TO DAMAGE

Ocean View Towing L. M. N. 1 1 N 01 2 2 N 01 3 2 N 03 Michalowski, Craig 4 5 6 7 8

N/A NAME AND ADDRESS OF EACH INVOLVED PERSON TRAFFIC UNIT # 1 OPERATOR OR PEDESTRIAN # TRAFFIC UNIT # 2 OPERATOR OR PEDESTRIAN # 471 North High St East Haven, CT 06512
Month Month Month Month Month Month Day Day Day Day Day Day Year Year Year Year Year Year

AA 24

Date of Birth

O. P. Q. 9 2 1 1 2 3 4 5 6 7 8

9 2 1

0 9 2 5 7 9 9 2 1

FORM PR-1 

4

Page # 2 of 4

Police Case Number

1300000856
INDICATE NORTH

ACCIDENT DIAGRAM

MAP NOT TO SCALE
TRAFFIC UNIT #

1
On

TRAVELING

TRAFFIC UNIT #

East

Sargent Drive

East

2
On

TRAVELING

Sargent Drive

On 1/17/13, at about 1730 hrs, information was given to me regarding a motor vehicle accident on Sargent Dr, New Haven involving a police vehicle. The accident was a result of an on going investigation, case number 13-846 (theft of purse), from the town of East Haven. Officer Bissette, (Driver) and Officer Michalowski, (passenger) of vehicle #2, both stated that as they were attempting to stop vehicle #1 for questioning related to the investigation. Officer Michalowski stated that as they were traveling eastbound on Sargent Dr, New Haven, Detective Ranfone (non-contact vehicle) was traveling directly behind vehicle #1 and they were behind Detective Ranfone's unmarked detective vehicle. He stated that he and Detective Ranfone had activated their emergency lights in order to make the motor vehicle stop. After a short distance of traveling east on Sargent Dr, it appeared that vehicle #1 was not pulling over so he instructed Officer Bissette to pull into the left lane and get alongside of vehicle #1 so he can hand motion her to pull over. Officer Michalowski stated that once alongside vehicle #1 he had made eye contact with the female operator of vehicle #1 who indicated to him that she was pulling over. He stated that as vehicle #1 was pulling curbside they had moved ahead of vehicle #1 in an attempted to pull curbside, at which time vehicle #1 struck their vehicle. I spoke to operator of vehicle #1 via telephone conversation, who stated that as she was traveling on Sargent Dr she had noticed a vehicle behind her with it's emergency lights on and a police vehicle on the left side of her. She stated that the officer in the passenger seat of the vehicle alongside of her was motioning for her to pull over. She stated that as she was pulling over and coming to a stop the police vehicle had pulled
DAMAGE TO PROPERTY OTHER THAN INVOLVED VEHICLES
1. DESCRIBE THE NATURE AND EXTENT OF PROPERTY DAMAGE NAME AND ADDRESS OF PROPERTY OWNER 2. DESCRIBE THE NATURE AND EXTENT OF PROPERTY DAMAGE NAME AND ADDRESS OF PROPERTY OWNER
REPORT DATE CASE STATUS SUPERVISOR

RANK AND SIGNATURE OF INVESTIGATING OFFICEROFFICER ID POLICE AGENCY IDENTIFICATION

0520 East Haven Police Depart01/18/2013

Closed

CONNECTICUT UNIFORM POLICE ACCIDENT REPORT
GPS READINGS: Latitude: Time:

FORM PR-1 REV.01/01

R A

00:00

Longitude:
ACCIDENT SEVERITY Fatal Injury X PDO # VEHICLES INVOLVED PAGE #

B

FOR DOT USE ONLY
POLICE CASE NUMBER
C D E F G

DATE OF ACCIDENT MILITARY TIME

0 1 1 7 1 3 1 7 5 6
TOWN OR CITY NAME

2

3 of 4
(Street Name or Route #)

A 1300000856
(Street Name or Route #)

TOWN CODE ACCIDENT OCCURRED ON

East Haven
IF NOT AT INTERSECTION 1. MEASURE DISTANCE (Check Appropriate Boxes)
H 1 S 1 T 1

AT ITS INTERSECTION WITH at

0 4 4
Feet Tenths Meters Kilometers Pedestrian 2. DIRECTION North South East of West

Sargent Drive

Interstate 95 South Entrance Ramp

3. NAME OF NEAREST INTERSECTING STREET, TOWN LINE OR MILE MARKER

Accident Occurred: TRAFFIC UNIT # OPERATOR # Vehicle

On Private Property Pedestrian

Parking Lot

TRAFFIC UNIT # OPERATOR #

H 2 S 2 T 2

Vehicle

Non-Contact Vehicle (Last, First, Middle Initial) PROPER LICENSE CLASS Yes No SEX M F
Year

Non-Contact Vehicle (Last, First, Middle Initial) PROPER LICENSE CLASS Yes No SEX M F
Year

or PEDESTRIAN NAME

or PEDESTRIAN NAME

ADDRESS (Street Number and Name)
J 11 J 12

ADDRESS (Street Number and Name)

J 21 J 22

CITY OR TOWN

STATE

ZIP CODE STATE

CITY OR TOWN

STATE

ZIP CODE STATE

OPERATOR LICENSE #

Month

DATE OF BIRTH
Day

OPERATOR LICENSE #

Month

DATE OF BIRTH
Day

U 1 K 11 K 12

OWNER'S NAME (Enter SAME if Owner is Operator) ADDRESS (Street Number and Name)

OWNER'S NAME (Enter SAME if Owner is Operator) ADDRESS (Street Number and Name)

U 2 K 21

CITY OR TOWN REGISTRATION #

STATE

ZIP CODE

BODY TYPE

CITY OR TOWN REGISTRATION #

STATE

ZIP CODE

BODY TYPE

K 22 V

STATE VEHICLE YEAR AND MAKE

STATE VEHICLE YEAR AND MAKE
W

VEHICLE IDENTIFICATION NUMBER

VEHICLE IDENTIFICATION NUMBER

CARRIER NAME CARRIER ADDRESS (#, Street, City or Town, State, Zip Code) SOURCE OF CARRIER NAME USDOT # Shipping Papers/Trip Manifest ICCMC # Driver Side of Vehicle GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACARD No 4 Digit # REQUIRED? Yes RATING # No 1 Digit # DISPLAYED? Yes

CARRIER NAME CARRIER ADDRESS (#, Street, City or Town, State, Zip Code) SOURCE OF CARRIER NAME USDOT # Shipping Papers/Trip Manifest ICCMC # Driver Side of Vehicle GROSS VEHICLE WEIGHT HAZARDOUS MATERIAL PLACARD No 4 Digit # REQUIRED? Yes RATING # No 1 Digit # DISPLAYED? Yes

X 1 Y 1 Z 1

}

}

X 2 Y 2

HAZARDOUS CARGO RELEASED? Yes No

ENFORCEMENT ACTION TAKEN Arrest Written Warning SUBJECT OF ACTION

None Verbal Warning Carrier Pedestrian

None Z HAZARDOUS CARGO ENFORCEMENT ACTION TAKEN 2 RELEASED? Yes No Arrest Verbal Warning Written Warning STATUTE OR ORDINANCE #'S SUBJECT OF ACTION Operator Owner Carrier Pedestrian
AA 21 AA 22 AA 23

STATUTE OR ORDINANCE #'S
AA 11 AA 12 AA 13 AA 14

Operator Owner

AUTOMOBILE INSURANCE -- NAME -- POLICY #

AUTOMOBILE INSURANCE -- NAME -- POLICY #

PARTS OF VEHICLE DAMAGED

PARTS OF VEHICLE DAMAGED TOWED DUE TO DAMAGE

VEHICLE TOWED TO:

VEHICLE TOWED TO:

TOWED DUE TO DAMAGE

AA 24

L. M. N. 1 2 3 4 5 6 7 8

NAME AND ADDRESS OF EACH INVOLVED PERSON TRAFFIC UNIT # TRAFFIC UNIT # OPERATOR OR PEDESTRIAN # OPERATOR OR PEDESTRIAN #

Date of Birth

O. P. Q. 1 2

Month Month Month Month Month Month

Day Day Day Day Day Day

Year Year Year Year Year Year

3 4 5 6 7 8

FORM PR-1 

4

Page # 4 of 4

Police Case Number

1300000856

TRAFFIC UNIT #

TRAVELING

TRAFFIC UNIT #

TRAVELING

On

On

ahead of her and was coming to a stop, at which time her vehicle rolled into the side of the police vehicle. Officer's Michalowski and Bissette were operating police vehicle #20, registration 103-EHA. Vehicle sustained minor damage to the right side front and rear door's. Damage was photographed and logged into evidence. There was no report of any injuries.

DAMAGE TO PROPERTY OTHER THAN INVOLVED VEHICLES

1. DESCRIBE THE NATURE AND EXTENT OF PROPERTY DAMAGE NAME AND ADDRESS OF PROPERTY OWNER 2. DESCRIBE THE NATURE AND EXTENT OF PROPERTY DAMAGE NAME AND ADDRESS OF PROPERTY OWNER
REPORT DATE CASE STATUS SUPERVISOR

RANK AND SIGNATURE OF INVESTIGATING OFFICEROFFICER ID POLICE AGENCY IDENTIFICATION

0520 East Haven Police Depart01/18/2013

Closed

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