Lac La Biche Detachment Protected B
Once Completed
Détachement de Lac La Biche
P.O. Box 810 / B.P. 810, 11 Nipewon Road
Motor Vehicle Collision Statement Lac La Biche, Alberta TOA 2CO
K Division Admin: 780 404-2500 Emergency: 780 623-4380
Fax/Téléc: 780 623-2588
Email/ Courriel : LLBAdmin@rcmp-grc.gc.ca
This information is being collected for the purpose of gathering additional or supplemental information from persons who have knowledge of an accident.
The information is collected and is disclosed in accordance with the Traffic Safety Act, Operator and Vehicle Licensing Control Regulation, and the
Freedom of Information and Protection of Privacy Act. Contact Alberta Transportation at (780) 427-8901 or toll free at 310-0000.
To obtain a copy of your collision report, please visit Alberta Transportation website
Date of Statement (yyyy-mm-dd) Time (hh:mm) File No. Investigator Name
Statement Provider
Full Name Date of Birth (yyyy-mm-dd)
Address
Home Telephone No. (Inc. area code) Work Telephone (Inc. area code) Cell Phone (Inc. area code)
Home Email Address Work Email Address
Driver’s License No. Province Issued Class Expiry Date (yyyy-mm-dd)
Animal Details Did the collision involve an animal? Yes No
Previously Reported Did you call 911? Yes No Was there a police officer at the scene? Yes No
Collision Details
Involvement (Choose All That Apply)
Driver Registered Owner Passenger Motorcyclist Bicyclist Pedestrian Other specify:
Date of Collision (yyyy-mm-dd) Day of Week Time (hh:mm)
Statement Provider was Address where Collision Occurred (as detailed as possible)
Driving Parked
Direction of Travel Nearest Town / City Distance From Nearest Town / City
North East South West
Safety Equipment Used
None Lap/Shoulder Belt Helmet Airbag Other – Specify:
Were you Injured?
No Yes – Please detail:
Did you or will you seek medical attention? Were you admitted to a hospital?
No Yes No Yes
Activity Engaged in While Driving
None Using hand-held cell phone or other hand-held electronic device
Reading, writing, grooming Using hands-free cell phone or other hands-free electronic device
Other
Passenger Details
How many passengers were in the vehicle?
1 of 4
Vehicle and Conditions
Estimated Speed of Vehicle (km/hr) Estimated Damage to Vehicle ($) Vehicle Appears Repairable?
Yes No
Vehicle Year/ Make/ Model Colour Licence Plate No. Province Issued
Vehicle Condition Contributing Factors
No Apparent Defect Defective Brakes Tires Failed Improper Load / Shift Lighting Defect Other - Specify
Initial Point of Impact (Circle diagram or select)
□ 01 – Front Passenger □ 05 – Rear Driver □ 09 – Roof
□ 02 – Passenger □ 06 – Driver □ 10 – Undercarriage
□ 03 – Rear Passenger □ 07 – Front Driver □ 11 – Rollover
□ 04 – Rear □ 08 – Front □ 12 - Attachment
Light Conditions (A) Light Conditions (B)
Daylight Sunglare Darkness Unknown No Artificial Light Artificial Light
Traffic Control Device
None Present Traffic Signal / Lights Stop Sign Yield Sign Merge Sign Pedestrian Cross Walk
Railroad Crossing Unknown
Traffic Device Condition
Functioning Not Functioning Obscured Missing N/A Other Specify:
Contributing Road Condition
No Unusual Condition Under Construction/Maintenance Holes / Ruts / Bumps Slippery When Wet Oily Pavement
Soft / Sharp Shoulder Unknown
Load Details (A) Load Details (B)
Loaded Unloaded Not Applicable Load Not Spilled Load Spilled Not Applicable
Trailer/ Attachments
Recreation Trailer Small Utility Trailer Farm Equipment Towed Motor Vehicle
Single Double Triple
If Single, Double, or Triple was selected above, please indicate which type.
Van/Box Body High Boy Car/Log/Livestock Carrier Dump Low Boy Tanker Other – Specify:
Road Alignment (A)
Level Grade Hillcrest Sag (bottom of hill) Unknown
Road Alignment (B)
Intersection Straight Curve Unknown
Environmental Condition
Clear Raining Hail / Sleet Snow Fog / Smog / Smoke / Dust High Wind Unknown
Surface Condition
Dry Wet Slush / Snow / Ice Loose Surface Material Muddy Unknown
Other Vehicle Details
Did the collision involve another vehicle? Direction of Travel of Other vehicle: Estimated Speed of Other Vehicle (km/hr)
Yes No
Vehicle Year Vehicle Make Vehicle Model Colour Licence Plate No. Province of Licence Plate
Driver’s Name Driver’s Licence No. Province Issued
Driver’s Address: Phone No. (include area code)
2 of 4
Insurance Company for Other Vehicle Policy No. Insurance Expiry Date (yyyy-mm-dd)
Draw a Diagram of the Collision Scene. Draw to the best of your ability. DRAWING MUST BE INCLUDED.
Please Include:
1) Point of Impact On All Vehicles Involved
2) Direction of Travel, which lane each vehicle was in, traffic signal(s) if any
E
W
S
Passenger Information
1 2 3
Name of Passenger
Gender
Date of Birth
[If unknown, write approximate
age]
Address
Phone Number
Where were they seated?
[Be Specific]
Seatbelt? Yes/No
Injuries? Yes/No
If yes, please describe:
3 of 4
Statement
It is unlawful to make a false statement. In the field below, please describe how the collision occurred and what action
you took before and after the collision. If this was a hit and run, please describe the vehicle and/or driver.
Details of Collison:
Any information you provide may be used for civil, criminal, or administrative proceedings. Do you understand? Yes No
I consent to the investigation law enforcement agency releasing a copy of this statement to any Yes No
person, agency, or other entity upon request.
Signature of Driver/Owner Date (yyyy-mm-dd)
4 of 4 Reset Form
