Kauai Police Department

Report Request Form

Business Name

Phone Number

Email of requestor

Email to receive the report

Case Information

Date of Report *

Case Number *

Type of Report: (Ex. Motor Veh Accident or MVA) *

Location of incident

Vehicle information

Insured Party

Vehicle VIN number

Vehicle Tag/ Plate #

Upload File(s)

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Sign Here

First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.