Free 42528.FH11 - Indiana

REPORT OF INDIANA OPERATORS BOAT ACCIDENT
State Form 42528 (R2 / 6-06) DEPARTMENT OF NATURAL RESOURCES

FOR OFFICE USE ONLY
USCG assigned number DNR case number

Please TYPE or PRINT. The operator of every vessel involved in an accident is required by Indiana Code 14-15-4-2 to file a report in writing if the accident results in loss of life, injury, or property damage in excess of $750. Reports must be mailed within twenty-four (24) hours to: Law Enforcement Division, Department of Natural Resources, 402 West Washington Street, Room W255-D, Indianapolis, Indiana 46204. ACCIDENT DATA
Date (month, day, year) City Water condition Calm Rough Strong current Very rough Day of the week Township Wind (MPH) None Light (0-6) Moderate (7-14) Strong (15-25) Storm (over 25) Actual local time County AM PM State Weather Clear Cloudy Age Fog Rain Snow Hazy Body of water Visibility Good Poor Telephone number Fair Night Number of boats Number of injuries / number of fatalities

OPERATOR 1
Name of operator 1 (last, first, middle initial) Address (number and street, city, state and ZIP code) Sex Male Female Date of birth (month, day, year)

(

)

VESSEL 1
Name of registered owner (last, first, middle initial) USCG documented (name and number) Registration number Year Length (feet) Make Hull identification number (HIN) Model Color

DAMAGE - VESSEL 1
Estimated damage Other property damage Describe damage (use accident description for more detail)

$
Name of object

$
Other damaged property (include cargo) Owners name and address Name of object Owners name and address

INSURANCE 1
Name of insurance company Name of agent Telephone number

(
Sex

)

Policy number

Policy applies to Owner Operator

OPERATOR 2
Name of operator 2 (last, first, middle initial) Address (number and street, city, state and ZIP code) Male Female Age Date of birth (month, day, year) Telephone number

(

)

VESSEL 2
Name of registered owner (last, first, middle initial) USCG documented (name and number) Registration number Year Length (feet) Make Hull identification number (HIN) Model Color

DAMAGE - VESSEL 2
Estimated damage Other property damage Describe damage (use accident description for more detail)

$
Name of object

$
Other damaged property (include cargo) Owners name and address Name of object Owners name and address

INSURANCE 2
Name of insurance company Name of agent Telephone number

(

)

Policy number

Policy applies to Owner Operator

OFFICER
Was officer at scene? Yes No Continued on reverse side Name of officer Department

VESSEL 1
Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident

VESSEL 2
Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident Injured Deceased Name (last, first, middle initial) Witness Age Date of birth (month, day, year) Telephone number

(

)

Address (number and street, city, state and ZIP code) Name of injury / cause of death / location at time of accident

DESCRIPTION OF ACCIDENT
Explain how the accident happened, including the sequence of events. If a diagram can be provided, please attach.

Printed name of person submitting this report

Signature

Date submitted (month, day, year)