b"INJURED / MISSING / DECEASEDNAME AND ADDRESS OF VICTIM AGE D.O.B. GENDER ONBOARD VESSEL WAS A PFD WORN? Treatment Beyond 1st AidM F Yes No Victim Was HospitalizedDEATH CAUSED BY: (If applicable) OtherMISSING TYPE OF INJURY LOCATION OF INJURYDrowning Trauma _____ Y NNAME AND ADDRESS OF VICTIM AGE D.O.B. GENDER ONBOARD VESSEL WAS A PFD WORN? Treatment Beyond 1st AidM F Yes No Victim Was HospitalizedDEATH CAUSED BY: (If applicable) MISSING TYPE OF INJURY LOCATION OF INJURYDrowning Trauma Other Y NNOTE: If more space is needed to list information concerning Injured / Missing / Deceased persons please attach a separate page. PROPERTY DAMAGEPROPERTY DAMAGE ESTIMATE PROPERTY DAMAGE DESCRIPTION $Vessel #1 $ Vessel Was A Loss.Vessel's ValueVessel #2 $Other Property (not vessel) $ACCIDENT DESCRIPTIONDESCRIBE WHAT HAPPENED (Include a sequence of events and what in your opinion caused the accident.Include or attach a diagram if needed. Continue on additional sheets of paper if necessary.)ALCOHOL / DRUG USEDid the operator consume any alcohol or do drugs before or during the operation of the vessel? A Little A Lot None Alcohol Drugs BothDid any of the passengers consume any alcohol or do drugs before or during the operation of theA Little A Lot None Alcohol Drugs Bothvessel?Was there any alcohol or drugs onboard during the operation of the vessel? A Little A Lot None Alcohol Drugs BothIf this accident involved more than one vessel, was there any indication that the operator of the otherA Little A Lot None Alcohol Drugs Bothvessel(s) had consumed any alcohol or done drugs?OTHER KEY CONTACT INFORMATION (If more than 2 vessels / property were involved, please attach a separate sheet of paper with this information.Other Vessel Operator Other Vessel Owner Owner of other damaged property Passenger on your vessel WitnessNAME AND ADDRESS PHONE NUMBEROTHER VESSEL REGISTRATION (if applicable)Other Vessel Operator Other Vessel Owner Owner of other damaged property Passenger on your vessel WitnessNAME AND ADDRESS PHONE NUMBEROTHER VESSEL REGISTRATION (if applicable)SIGNATUREThe information on this form is certified under penalty of false statement to be true and complete.X Signature of person completing this report Date Printed name of person completing this reportAddress (Street, Town, State)PhoneINVOLVEMENT: Operator OwnerWitness: Other:This form is available on-line in a PDF version you can fill out on your computer.Visit: www.portal.ct.gov/boating662021 Connecticut BOATERS GUIDE"