HomeMy Public PortalAboutPRR 20-2797IRAN: 1056164062 REPORT REQUEST'®
PLEASE CHECK A INSURANCE COMPANY NAME:
CIRCLE BELOW STATE FARM CLAIMS COMPASS 6/24/20 I I I IIII I I III IIIIIIII I I III I I II I II I I III 11i I 1I1 I
0 Report Attached:
Report Cost: $ Number of Pages:
(including this sheet)
ONo Report Found with the information provided
ONo Report Written - Log entry only / Driver Exchange of Info.
OLoss location not in our Jurisdiction
Suggest You Try:
O Not Releasable / Not Ready
OComments & Suggestions:
LOCATION OF LOSS
LexisNexis®
P.O.BOX 740167
ATLANTA,GA 30374-0167
(678)924-4900 FAX (678)924-4901
TOLL FREE PHONE:
1/800-934-9698
TOLL FREE FAX.
1/800-934-6449
EMAIL REPORTS:
cru.incoming@lexisnexisrisk.com
RePort/Case # 20-1070
Type of Report Auto Theft
Date of Occurrence 6/14/20 Time 0:0:0
Precinct or District
1420 N OCEAN BLVD
City GULF STREAM County PALM BEACH State FL
Additional Information
VEHICLE INFO
Car Tag #
DRIVERS or VICTIMS INFO
State Insured Party DEBORAH A SARGEANT
Make LAND ROVER Year 2020 D.O.B. 8/21/58 SS#
VIN SALGW5REOLA591379 Drivers Lic # S625161588010 State FL
POLICE or FIRE AGENCY who wrote report? Driver #2
GULF STREAM PD 11.647 Driver #3
Client 6625 Claims Adjuster KPQ2
Division Claim # 5907Z472J
Internal Codes 111111111111111111111 TRAN: 1056164062
Page 1 of 1
DRAW Police Dept.: Please Return This Form With Your Response... Thanks (Rev. 3/19)
a l ar�I'pp
ocuSign Envelope ID: 057D2367-308F-4212-9DDC-B1 E2768637F2
S#ateFarm,
LexisNexis Risk Solutions, Inc. March 12, 2020
Attn: Claims Record Unit
2885 Breckenridge Blvd. Suite 200
Duluth, GA 30096
To whom it may concern:
By this letter, State Farm Mutual Automobile Insurance Company hereby authorizes
LexisNexis Risk Solutions, Inc. to obtain police reports, fire reports and/or public
documents on our behalf. Our purpose for ordering these reports is for insurance
purposes only.
This authorization is valid from the date signed below through April 4, 2021.
Authorized By:
DocuSigned by:
&AuI S&440"
Signature
Schuyler Schupbach
Printed or Typed Name
VPo - P&C Claims
Title
3/14/2020 1 08:53:34 AM CDT
Date EFFECTIVE DATE: 03/14/2020
CLAIM NUMBER: 5907Z472J
LEXISNEXIS TRANSACTION ID: 1056164062
INSURED / INVOLVED PARTY: DEBORAH SARGEANT
PRINTED: 6/24/20
ADJUSTER:
Providing Insurance and Financia! Services Nome Office, Bloomington, IL
fllaw3new
1056164062
5907Z472J
Sworn Statement for Trak Crash Report Information
Motor Vehicle crash information is confidential and exempt from disclosure foraperiod of 60 days afterthe crash report is
filed. §316.066(2) (a) Florida Statutes (2016). Obtaining confidential information by someone who knows they are not
entitled to do so is a felony violation.
Theundersigned requests thefollowingcrashreport(date/location/parties):
6/14/20 1420 N OCEAN BLVD DEBORAH SARGEANT
The undersigned states that he/she or the organization represented qualify for immediate disclosure of the crash report
according to the exemption checked below and does swear or affirm that the information contained in a crash report
made confidential by statute will not be used far any commercial solicitation of accident victims, or knowingly be disclosed
to any third party for the purpose of such solicitation, during the period of time that the information remains confidential.
_l am a party involved in the crash
_I am a legal representative to a party involved in the crash:
Florida Bar Number:
_I am a licensed insurance agent to a party involved in the crash, their insurer or insurers
to whichthey appliedforinsurancecoverage, FloridaLicenseNumber:
X I am a person under contract to provide claims or underwriting in formation to a
qualifying insurance company, identified as: STATE FARM CLAIMS COMPASS
I am a prosecuting authority, Florida Bar Number:
I represent a radio or television station licensed by the FCC or newspaper qualified to
publish legal notices or an free newspaper of general circulation, as defined in 316.066(2)(b)(2016), Florida Statutes.
Name ofRadio/Television/Newspaper:
_I represent a local, state or federal agency that is authorized bylaw to have access to
these reports.
Name of local/state/federal agency:
1 represent a Victim Services Program, as defined in 316.003(85), Florida Statutes (2016).
Name of Program:
NYREE WILLIAMS LEXISNEXIS CLAIMS SOLUTIONS INC.
rinted Name Agency/Business/Represented
P.O.BOX 740167
Address
Signature
(678)924-4900 FAX (678)924-4901 �LANTA,GA 30374-0167
(Area Code) Telephone Number City, State, Zip Code
GEORGIA
Stateof Florida, County of GWINNETT 6/24/20 NYREE WILLIAMS
Sworn (or affirmed) and subscribed before me this_day of 20_ by
Personallyknown Xorproduced identification_Type of Identific Produced:
[VcoDf—Q 011�L./
Print Type or Stamp, Commissioned Name of Notary Suture ofNotaryPubhc or Certified Law
Enforcement or Correctional Officer s�°°°,N111 I, ���
/.1
HSMV-94010 (Rev. 11/16)
TOWN OF GULF STREAM
PALM BEACH COUNTY, FLORIDA
Delivered via e-mail
July 6, 2020
Lexis Nexis [mail to: PO Box 740167, Atlanta GA 30374-9980]
Re: GS #2797 (Police Report)
Would like a copy of police report #20-1070.
Dear Lexis Nexis [mail to: PO Box 740167, Atlanta GA 30374-9980]:
The Town of Gulf Stream has received your public records request 7/6/2020. You should be able
to view your original request and response at the following link:
http://www2.gulf-stream.org/weblink/0/doc/171648/Page1.aspx
The Police Report is also attached for your convenience. As this is an active criminal
investigation, the supplemental reports have not been provided. If your request seeks
supplemental police investigation reports, please let us know.
If the Town does not hear back from you within 30 days of this letter, we will consider this
request closed.
Sincerely,
Reneé Rowan Basel
As requested by Rita Taylor
Town Clerk, Custodian of the Records
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L i c e n s e S t a t e : F L
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I n s u r a n c e C o m p a n y : S T A T E F A R M
I N C I D E N T S U M M A R Y
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B R O W N W A N T E D T O R E P O R T A D E L A Y E D A U T O T H E F T O F A 2 0 2 0 R A N G E R O V E R S P O R T S W A G O N ( F L . T A G
Fage l of L
PADY66) REGISTERED TO HARRY SARGENT.
Complamt Number: 2U- l U /U
UPON ARRIVAL I MET WITH MR BROWN WHO ADVISED THE BLACK RANGE ROVER WAS TAKEN FROM THE
FRONT EAST DRIVEWAY ON 6/14/2020 AT 1415 HOURS THE KEYS WERE IN THE VEHICLE. THE THEFT WAS
CAPTURED ON THE HOME SECURITY CAMERAS. THE CAMERAS SHOWED TWO W/M'S WEARING HOODIES
COME ONTO THE COMPOUND FROM AN UNKNOWN DIRECTION AND THEN LEAVE DRIVING OUT THE EAST
GATE IN THE RANGE ROVER.THE FAMILY WAS HOME DURING THE TIME OF THE THEFT. THE VICTIMS
GUARD DOGS WERE IN THE HOUSE
THE VICTIMS WERE UNSURE IF ANY OF THE OTHER VEHICLES PARKED ON THE PROPERTY WERE TAMPERED
WITH.
SECURITY ADVISED THEY WOULD PLACE THE SECURITY FOOTAGE ON A THUMB DRIVE AND BRING IT TO
THE STATION.
A FAMILY MEMBER TRACKED THE THE VEHICLE ON THE VEHICLE GPS AND THE LAST KNOWN LOCATION
WAS 1350 NE 5TH AVE IN FT LAUDERDALE ON 6/14/2020 AT 1600 HOURS. SERGEANT O'DONNELL CONTACTED
DELRAY POLICE DISPATCH WHO ALERTED BROWARD SHERIFFS OFFICE.BROWARD SHERIFFS OFFICE
CHECKED THE FT LAUDERDALE ADDRESS ,WITH NEGATIVE RESULTS.
THE VALUE OF THE VEHICLE IS 217.000.00
THE THEFT AFFIDAVIT WAS EMAILED TO DELRAY BEACH POLICE DISPATCH AND ENTERED AS STOLEN IN
NCIC/FCIC.
INVESTIGATION CONTINUES AWAITING SECURITY FOOTAGE.
NO OTHER INFORMATION AT THIS TIME.
PALM BEACH COUNTY MULTI—AGENCY AUTO THEFT TASX FORCE
STOLEN VET-X=Z, VF4$-jjL AST/I�DAVIT
Agency: t°' 'r't *�� Agency Case No. _
MMJ
essel: Mull Material: o or: .
ngine Make: Value:
Trailer maice: icense:az_e:. Value:
, swear or aff_rm that the above listed vehicle/vessel
(circle one) was taker without my consent, either expressed or implied, from the location listed.
I further swear or affirm that I do/do not (circle one) knew the identity of the suspect except as listed on the
complaint form and that I am authorized to report this vehicle/vessel (c_rcle one) stolen as the owner or person
having legal possession of it at this time.
I release any and all law enforcement agencies from any and all legal liability for any damage or injury
incurred while apprehending the operator or recovering the vehicle/vesse_ (circle one). I understand the
seriousness of giving false information to law enforcement agencies. I 'further swear and/or affirm that I will
prosecute the offender(s) if apprehended and will appear and testify in a court of law. There will be no
dismissal of said charges and that exchanging the vehicle for property or drugs or false police reports can
result in my prosecution for felony offenses and/or forfeiture of said vehicle.
I do hereby voluntarily make the following statement and/or answer the following questions without threat,
coercion, offer of benefit or favor by any pe 3ona,whomsoever._ A
1. Persons) authorized to use vehicle:
2. Was vehicle loaned out? (If yes, to whom and what time period?): Z:)
3. Location of keys and/or vehicle:___
4. Are you behind on any finance payments? ( yes, ow many?):
5. Personal property in vehicle:
6. Did vehicle have anti -theft device or etching?a�1C /
VICTIM STATEM NT (Pxomm=) Describe events wszounding the theft to
vehicle and evidence found, or Property left in the vehicle:
date/time you last saw the
Sworn to and subscribed before me, I Swear/Affirm the above and/or attached
this a of � , ��Oby statements are correct and t e:
Notary p c/ of cement Officer Victim Signature:
Pprnr%nm 1 1 v L....._... -_
- Court Green - State Atty. Yellow - ATTF/PESO ?ink - File
1