Accident Report - Hunter e33 Operator's Manual

U.S. Dept. of Homeland Security
U.S. Coast Guard CG-3865 (Rev. 07-08)
NOTE: each boat operator/owner involved in an accident should submit a separate report.
Estimated report form completion time: 30 min
For each question below, please provide answers
REPORT SUBMISSION
Report required because (select all that
At least one person in this accident died :
At least one injured person in this accident required or was in need of
treatment beyond first aid:
At least one person in this accident disappeared and has not
yet been recovered:
All boat and other property damage
by this accident totaled (or likely totaled) $2,000 or more:
Approximate value of damage to your boat:
Approximate value of damage to your other property:
Your or another boat in this accident was (or likely was) a total loss
Report submitted by (select all that
Boat Operator (required if possible)
Boat Owner (if operator unable, or same as operator)
Other (describe):
First name:
Phone:
ACCIDENT SUMMARY
WHEN
Date:
Time: :
WHERE
Body of water name:
Location (on water)
description:
Nearest city/town:
County:
State:
YOUR BOAT - PEOPLE
# people on board (including
# people being towed (e.g., on tubes,
# people wearing lifejackets
OTHER BOATS INVOLVED IN ACCIDENT
# of other boats involved?
U.S. Dept. of Homeland Security
Recreational Boating Accident Report
apply):
If so, how many?
If so, how many?
If so, how many?
(e.g., fishing/hunting gear)
apply):
Last name:
- -
mm/dd/yy
am pm (select one)
operator):
skis):
(on board or towed):
U.S. Coast Guard CG-3865 (Rev 07-08)
IF APPLICABLE AND IF KNOWN
caused
$
$
ACCIDENT DESCRIPTION
Briefly describe this accident
DAMAGE TO YOUR BOAT
Briefly summarize any damage to your boat:
DAMAGE TO YOUR OTHER PROPERTY (NOT BOAT)
Briefly summarize any damage to your other property (not boat):
, otherwise leave blank.
To be submitted within:
48 hours (if injury, disappearance or death)
10 days (if boat/property damage only )
To be submitted to:
(Local State Reporting Authority)
Phone: ( )
You may submit any comments concering the the accuracy of the burden estimate or
any suggestions for reducing the burden to: Commandant (CG-5422), U.S. Coast
Guard, Washington, DC 20593-0001 or Office of Management and Budget,
Paperwork Reduction Project (1625-0003), Washington, DC 20503.
For State Agency Use Only
First name:
Last name:
Phone:
Primary cause of accident:
(attach extra pages if
OMB No: 1625-0003
Expires: 7/31/2011
necessary):
Page 1 of 6