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HomeMy Public PortalAboutPRR 21-2852 Renee Basel From:Ellainne Torres <etorres@lawclc.com> Sent:Thursday, September 2, 2021 10:24 AM To:Rita Taylor Subject:DOL: 8/27/2027 - Pugliese \[NOTICE: This message originated outside of the Town of Gulfstream -- DO NOT CLICK on links or open attachments unless you are sure the content is safe.\] Dear Records Custodian: Please be advised this firm represents the passenger, Mr. Anthony Pugliese for an accident that occurred on August 27, 2021 as they were traveling A1A. The case number to the report was not provided. Please accept this email as a formal request to obtain a copy of the police report. Enclosed is a sworn affidavit. Please advise of any charges for this request and I will remit payment immediately. Thank you for assistance The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Ellainne F. Torres, Assistant to Al Benavente 303 Banyan Boulevard | Suite 400 | West Palm Beach | FL 33401 Phone: (561) 842-2820 | Fax: (561) 844-6929 Direct: 561-515-3141 ETorres @lawclc.com | www.lawclc.com The The linked linked image image cannot cannot be be displaydisplay PLEASE NOTE NEW EMAIL AND WEBSITE ADDRESS. ed. …ed. … This e-mail contains legally privileged and confidential information intended only for the individual or entity named within the message. Should the intended recipient forward this message to another person or party, that action could constitute a waiver of the attorney/client privilege. If the reader of this message is not the intended recipient, or the agent responsible to deliver it to the intended recipient, you are hereby notified that any review, dissemination, distribution or copying of this communication is prohibited. If this communication was received in error, please notify us by reply e-mail and delete the original message. 1 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail September 3, 2021 Ellainne Torres [mail to: etorres@lawclc.com] Re: GS #2852 (Police Report 21-1728) Please accept this email as a formal request to obtain a copy of the police report. Enclosed is a sworn affidavit. Dear Ellainne Torres [mail to: etorres@lawclc.com]: The Town of Gulf Stream has received your public records request dated September 2, 2021. I have attached the report to the e-mail for your convenience, as Motor Vehicle Crash Reports are confidential for a period of 60 days after the report is filed and they are not available to the general public during this time. On November 3, 2021, after expiration of the 60-day period, per Florida Statute 316.066(2)(a), you should also be able to view your original request and response at the following link: https://portal.laserfiche.com/Portal/DocView.aspx?id=176867&repo=r-430100cc We consider this request closed. Sincerely, Reneé Rowan Basel As requested by Rita Taylor Town Clerk, Custodian of the Records VEHICLE # I Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 21-1728 1 87073133 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN 2 Parked Motor VehiGe 1 Check rf Permanent 3 Working Vehicle HHRH74 FL 106/30/2022 Registration ❑ IGNSCGKCSGR416428 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 2016 CHEV UT UTILITY WHITE - WHI 2 Functional 88 I 88 Unknown 3 None Unknown $25,000.00 ll INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER T1'0No wed due VEHICLE REMOVED BY 1. Rotation TRAVELERS CASUALTY INS. 3N9408316A Damage: a 3. Driver 2. r Request 2 Yes ZUCCALA 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY & STATE ZIP OCEAN LEASING LLC 101 PUGUESE WAY DELRAY BEACH FL Spµ Trager LICENSE NUMBER STATE REGISTRATION EXPIRES Check If Permanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING El ❑ El ❑ ❑ ISRAIA NORTH OCEAN BLVD. 35 35 2 HAZ. MAT. RELEASED MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1 No JHAZ. 1 No ❑ 01 02 2 Yes 2 Yes 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 Unknown 88 Unknown MOTOR CARRIER NAME US DOT NUMBER 1 15 16 17 6 20 Windshield 20 1 15 16 17 6 14 13 121110 g 19 Overturn 19 21 Trailer 21 14 13 1211 0 g MOTOR CARRIER ADDRESS CITY T77 ODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility VehiGe ❑ 1 Two -Way, Not Divided 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 16 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 17 Cargo Van (10,0001bs 2 Two -Way, Not Divided, with a 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify (4,53o kg) or less) Continuous Left Divided, Lane more than 10,000 Ibs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 3 Single -Unit Truck (3 or more axles) occupants, including driver) 4 Truck Pulling Trailers) 3 Pickup (4,536 kg) or less) 4Two-Way, Divided, Positive 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Truck Tractor (bobtail) eavy Trucks (more Median Barrier occupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Trafficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type 13 Internodal Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport ❑ El 4 Saddle Mount/Trailer 77 Other5 Boat Trailer Narrative, Explain in El 3 closed Box Container Chassis 1 Interstate Cartier Hopper 4 Hopper Vehicle Towing 2 Intrastate Cartier 5Poie-Trailer Another Vehicle El 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 7 House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 2 Bus 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision Comm ❑ 1 10,000 Ibs (4,536 kg) or less 8 Dump displaying kg) or less not 1 Overtum/Rollover GVWR/GCWR 4 2 10,001-26,06000 lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 2 Fire/Explosion 3 More than 26,000lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not A Iiceble 11 Garbage/Refuse Narrative 4 Jackknife Collislon with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shin 10 Pedestrian 29 Cable Barrier Emergency 14 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 19 Impact Attenuator/Crash Cushion 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Rahway Vehicle (V20 Bridge Overhead Structureain, engine) 31 Other Traffic Barrier Sequence Of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support 22 Bridge Rail 32 Tree (standing) 1 9 Other Non -Collision 14 Motor Vehicle in Transport 33 Utility Pole/Light Support 1st 2nd 15 Parked Motor VehiG23 Culvert e 34 Traffic Sign Support ❑ 14 ❑ 140-46 Sequence of Events only) 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 2 Yes 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd 4th 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, ❑ 43 Ran Off Roadway, Left 18 Other Non -Fixed Object building, nnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Level ❑ 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest I 5 TurnLeaving Traffic Turning Right 16 Ling TLane 9 Railway Crossing Roadway Alignment 1 No Controls ross2 Brakes 13 Wheels 3 1 Uphill Lanes 17 Entering Traffic Lane hill 6 Changing Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including I 2 Curve Right Device 4 Lights (head, Windshield 5 Sag (bottom) t 11 Making U-Tum 88 Unknown 5 Traffic Control Flagman, Officer, signal, tail) 15 Mirrors 3 Curve Left 11 Overtak n assin Guard, etc.) Signal 77 Other, Explain in 6 Steering 16 Truck Coupling Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ 2 Farm Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign Narrative 9 Exhaust System Safety Chains 1 of Motor Vehicle 3 Police 11 Farm Labor Transport 16 Shuttle Bus 88 Unknown 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 1 12 Suspension 88 Unknown VIOLATION PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER I PHILIP ANDREW PIKE 316.1925(1) CARELESSDRMNG AIPKOTP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 5 VALENTIN NOVIK 316.1945(1)(A)3 MPROPER STOP WITHIN INTERSECTION AIPKOVP HANOVIC PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 8 Page of _ FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH? LONG FORM SHORT FORM ❑ UPDATE ❑� TOTAL # OF VEHICLE SECTION(S) 2 (Shaded Areas) 2 MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TOTAL # OF PERSON SECTION(S) TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER T8S7073133 MV CRASH REPORT NUMBER 08/2712021 10:02 PM 09/11/2021 121-1728 CRASH IDENTIFIERS COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF IN IME REPORTED TIME DISPATCHED 08 PALM BEACH GULF STREAM CITY LIMITS �� 10:04 PM 10:04 PM TIME ON SCENE ME CLEARED SCENE I CHECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist ❑2 10:07 PM 111:59 PM COMPLETED a 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # AT LATITUDE AND LONGITUDE SRAIA 3500 BLOCK In 28.496914 -80.053473 AT FEET MILES N S E W ATIFROM INTERSECTION WITH STREET, ROADMIGHWAY © OR FROM MILEPOST # 5 ! .11e] :_A _ I BANYAN RD Road System Identifier 7 Forest Road Type of Shoulder Tyypp@@ of Intersection 5 Traffic Circle 3 ❑ 1 Interstate 4 County 2 U.S. 5 Local 8 Private Roadway 9 Parking Lot 1 Paved 2 2 Unpaved ❑ 1 Not at lntersectian 2 Four -Way Intersection 3 T-Intersection 6 Roundabout 7 Five -Point, or More 77 Other. Explain in Narrative 3 State 6 Tumpike/Toll 77 Other, Explain in Narrative 3 Curb 4 Y-Intersection CRASH INFORMATION ( HE K IF PICTURES TAKEN) Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact ❑ 1 Daylight 4 2 Dusk 5 Dark Not Lighted 6 Dark -Unknown 4 Flog, Smog, Smoke 5 Sleet/Hail/ 1 Freezing Rain 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 1 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn Lighting 6 Blowing Sand, Soil 1 8 Water 1 Directly Involved 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Narrative Dirt 1 Clear (standing/moving) 3 Yes, School Bus 1 Front to 7 Rear to Rear Rear 88 Unknown 7 Severe Crosswinds 2 Cloudy 1 Dry 77 Other, Explain in 2 Wet Narrative Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 77 Other, Explain in 3 Rain Narrative 4 Ice/Frost 88 Unknown 3 Angle 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 OvertunVRollover 10 Pedestrian 19Impact Attenuator/Crash 30 Concrete Cusion Barrier Location 1 On Roadwa 2 Fire/Explosion 11 Pedalcycle 31 Other Traffic 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) y 2 Off Roadway 14 ❑ 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 5 Cargo/Equipment 13Animal 22 Bridge Rail 34 Traffic Sign Support 3 Shoulder 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in 23 Culvert 35 Traffic Signal Support 6 Gore 6 Fell/Jumped From Transport 24 Curb 36 Ohter Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Parked Motor Vehide 25 Ditch Support 8 In Parking Lane or 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 9 Outside Right-of-way 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Ob'ect First Harmful Event Relation to Contributing Circumstances: Road g Worn, Travel -Polished Surface Contributing Circumstances: Environment 2 ❑ Junction 5 Railway Grade Crossing 1 icy, snow, slush, etc.) ❑ El ❑ 10 Road Surface Condition (wet, ❑ ❑ ❑ 14 Entrance/Exit Ramp 11 Obstruction in Roadway 1 Non -Junction 15 Crossover - Related 16 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animal(s) in Roadway Y 2 Intersection 17Acceleration/Dceleration Lane 4 Work Zone (construction/ Inoperative, Missing or Obscured P 9 2 Weather Conditions 77 Other, Explain in 3Intersection-Related 18 Through Roadway maintenance/utility 14 Non -Highway Work 3 Physical Obstruction(s) Narrative 4 Driveway/Alley Access 77 Other, Explain in Narrative 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 4 Glare 88 Unknown Related 88 Unknown 7 Rut, Holes, Bumps 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone Law Enforcement In Work 1 Before the First Work Zone 1 Lane Closure Zone 1 No 1 2 Yes Warning Sign 2 Advance Warning Area 3 Transition Area ❑ 2 Lane ShifUCrossover 3 Work on Shoulder or Median 4 Intermittent or Moving Work ❑ 1 No 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activity Area 77 Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present rNESSES NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE VEH. # PER # [ROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # [ROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME ❑ (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 8 Page of _ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 21-1728 87073133 1 Driver VEHICLE # NAME PHONE NUMBER Check if I�I LI 2 Nan -Motorist 1 ❑ 1 111561) 673-4248 Recommend 3 Passenger PHILIP ANDREW PIKE Driver Re -exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ODE 4100 SANCTUARY LN BOCA RATON FL 31 r33 DATE OF BIRTH SEX: 1 Male DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 2 Female 2 Possible 04/07/1967 88 Unknown P2006616712700 FL 04/07/2025 3 Non -Incapacitating 6 Non -Traffic Fatality DRIVER OIL Type Required Endorsements let Driven Actions at Time of Crash 3rd Condltion At Time of 1 off er 1 No Contribution Action 26 mega Negligent a ner in Carelss or 27 dad oothCrash 9D Traffic El rator r F 5 E/Ope2 No 1 Apparently Normal 6 E/Oper-Rest 3 No Re . Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road Q 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5111 (sick) or Fainted 6 Improper Turn 29 Over-Correcting/Over Driver Distracted By 6 Seizure, Epilespsy, Blackout 4 Other Inside the Vehicle Steering (explain in narrative) 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 2nd 8 Emotional (depression, 5 External Distraction 11 Ran Red Light 66 30 Swerved or Avoided : Due 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, 4th angry, disturbed, etc.) Devices (cell phone, etc. in narrative) 13 Ran Stop Sign Object, Non -Motorist in 9 Under the Influence Medications/Drugs/Alcohol El 3 Other Electronic Device 77 Other, Explain in Narrative device, DVD player) 61na Taxiing 15 Improper Passing Roadway, etc. xP r (navigation P Y 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, 88 Unknown 21 Wrong Side of Wrong Way Reckless or Agreessive Manner 88 Unknown 25 Failed to Keep in Proper Lane 77 Other Contributing Action DRIVER VISION OBSTRUCTIONS 1 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 1 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain ❑ 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) 3 Restraint Systems 1 DOT -Compliant 1 Yes (RS) DRIVER OR PASSENGER 1:1 SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) (LOC) 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant Seat ROW Other 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed 5 Lap Belt Only 2 Might 2 Sleeper Section of Truck Cab 5 Deployed -Other y Used 2 3 Right ThirdSecond 3 Other Enclosed Cargo Area Ejection (EJECT) (knee, air belt, etc.) 6 Restraint Used - Type Unknown 1 Not Ejected a 1 Nol Applicable 6 Deployed- 7 Child Restraint System - Forward Facing 77 Other 3 Third 4 Unenclosed Cargo Area (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System - Rear Facing 5 Trailing Unit 1 ❑ narrative 3 Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- Partially 3 Deployed -Front 7 Deployed -Curtain 10 Child Restraint Type Unknown 88 Unknown 88 Unknown � y 4 Deployed -Side 88 Deployment trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown NON N n iMotorist Description 1 Pe�estnan ❑ Non -Motorist Location At Time of Crash g Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk 9 MediaNCrossing Island 2 Other Pedestrian (wheelchad, person in a 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 In Roadway —Other (working, building, skater, pedestrian conveyance, etc. 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 1 Crossing Roadway 3 Bicyclist 4 Other Cyclist 7 Adjacent to Raodwa e 4 Marked Crosswalk J Y( 9, 12 Non-Trafficway Area 2 Waiting to Cross Roadway y 5 Occupant of Motor Vehicle Not in Transport P p Travel L- shoulder, median ) 5 Travel Lane -Other Location Walking/Cycling Along 77 Other, Explain in Narrative 3Roadway 8 Goingto or from School K-12 6 Bicycle Lane ( ) (parked, iAI 88 Unknown Roadwa with Traffic (in or 7 shoulder/Roadside J y ) 9 Working in Trafficway to travel lane Occupantadjacent of a Non -Motor Vehicle (incident response) 4 Walking/Cycling Along Transportation Device 7 Unknown Type of Nan -Motorist Non -Motorist Action rcums nces 10 None 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 1st ❑ 2 Dart/Dash or adjacent to travel lane) 3 Failure to Yield Right -of -Way 88 Unknown 4 Failure to Obey Traffic Signs 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used ❑ Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 2M Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) 5 In Roadway Improperly (standing, 8Inattentive (talking, g, ) Wrong -Way g lying, working, playing) ( g, satin etc 12 Wron Wa Riding or Walking in Narrative 4 Reflective Clothing (jacket, 88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: 1 No 1 Test Not Given 2 Test Refused ❑ 1 Blood 2 Breath 3 Urine ❑ EST RESULT: 1 ❑ NG DRUG USE: 1 1 No 2 � Test Not Given Test ❑ Refused 1 Blood 1 Positive ative ❑ 2 Yes 3 Test Given 77 Other, Explain 2 CO PPENDIL TED Y s 3 Test G ven 77 Other, 3 Pend ng 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, it Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON If IVEHICLE77 DATE OF BIRTH INJ I SEX I LOC: S I R 0 EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nat T-p- 2 EMS S law Enlacwnefn T/ p ,, Ep4 in Nan S8 Jn1 w ❑ PERSON # IVEHICLE7 DATE OF BIRTH INJ I SEX I LOC: S I R 0 EJECT HU EP ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NW Tmmp W 2 EMS S law En- Tl (Mim. E pW,n r NanRke 68 Unknown ❑ JEMS HSMV 90010 S 3 8 Page of_ PERSON # s 1 Driver VEHICLE # NAME 2 Non -Motorist 2 l I 1 3 Passenger VALENTIN CURRENT ADDRESS (Number and Street) 2060 OLEANDER BLVD APT 3 104 DATE OF BIRTH SEX: DRh 1 Male 2 Female �LL 02/17/1959 88 Unknown ❑ DL Type 3 Required Endorsements ❑ 4 4 D/ChChauffeur 5 E/Operator 6 E/Oper-Rest 1 Yes 2 No 3 No Req. Endorsement 7 None Distracted By 4 Other Inside the Vehicle ❑Driver (explain in narrative) 1 Not Distracted 5 External Distraction 2 Electronic Communication (outside the vehicle, explain Devices (cell phone, etc. in narrative) 3 Other Electronic Device 6 Texfing (navigation device, DVD player) 7 Inattentive 88 Unknown Reporbg Agency Case Number HSMV Crash Report Number 21.1728 87073133 PHONE NUMBER Check if Recommend ❑ IVANOVK:H NOVIK Driver Re -exam CITY 8 STATE ZIP CODE FORT PIERCE FL 34950 UMBER STATE r PIRES INJURY SEVERITY (INJ) 4lncepacitating 1 None 5 Fatal (within 30 days) 2 Possible 6 3 Non -Incapacitating Non -Traffic Fatality 1st Driven Actions at Time of Crash ❑1 No Contribution Action 2 Operated MV in Carelss or 26 Ran off Roadway 27 Disregarded other Traffic Negligent Manner Sign 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 4 Improper Backing Markings 6 Improper Turn 29 Over-Correcting/Over Steering 2nd 10 Followed too Closely 11 Ran Red Light 30 Swerved or Avoided : Due Drove too Fast for Conditions to Wind, Slippery Surface, MV, ❑12 13 Ran Stop Sign Object, Non -Motorist in 15 Improper Passing Roadway, etc. 17 Exceeded Posted Speed 31 Operated MV in Erratic, 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action ❑ 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) DRIVER OR PASSENGER ❑ 1 DOT -Compliant SEAT ROW OTHER Motorcycle Helmet Motor Vehicle Seating Position: LOCATION: 2 Other Helmet Seat Row Other (LOC) 3 No Helmet 1 Left 1 Front 1NotApplicable Air Bag I 3rd 4th DRIVER OR PASSENGER Condition At Time of Crash 1 Apparently Normal 3 Asleep or Fatigued 5 III (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medicabons/Drugs/Alcohol 77 Other, Explain in Narrative 88 Unknown Eye Protection (EP) ❑ Restraint Systems ❑ 1 Yes IRS) 2 No 3 Not Applicable 1NotApplicable(non-motorist) 2 None Used - Motor Vehicie Occupant 3 Shoulder and Lap Belt Used 4 Shoulder Belt Only Used 2 Middle 2 Sleeper Section of Truck Cab " ed 5 Deployed -Other 5 Lap Belt Only Used 3 Right 2 Second g (knee, air belt, etc. 3 Other Enclosed Cargo Area Ejection (EJECT) ) 6 Restraint Used -Type Unknown 77 Other 3 Third 1 Not Ejected 1 Not Applicable 7 Child Restraint System - Forward Facing 4 UnenGosed Cargo Area PP cable 6 Deployed - (explain in 4 Fourth ❑ 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System - Rear Facing narrative) 5 Trailing Unit 3 Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- / 3 Deployed -Front 7 Deployment 88 Unknown 88 Unknown Partially 4 Deployed -Side U Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N n-11Sotorist Description Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Pekpestnan 1 Intersection - Marked Crosswalk E 5 Walking/Cycling on Sidewalk ❑ 2 Other Pedestrian (wheelchari, Person in a ❑ 9 Metlian/Crossing Island $ building, skater, pedestrian conveyance, etc. 77 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 In Roadway — Other (working, 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 3 Bicydist 1 Crossing Roadway 4 Midblock -Marked Crosswalk 12 Non-Treffikway Area 2 Waitn to Cross Roadway 7 Adjacent to y (e.g., 4 Other Cyclist 5 Travel Lane - Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 88 Unknown 8 Going to or from School (K-12) (parked, etc.) Roadway with Traffic (in or 7 shoulder/Roadside (iWorking s response) 6 Occupant of a Non -Motor Vehicle adjacent to travel lane) Transportation Device on- o on rcum nces 4 Walking/Cycling Along 10 None ncident response) 7 Unknown Type of Non -Motorist ❑ 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narative tst 1 2 Darl/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 1 None Safety Equipment 5 Lighting 4 Failure to Obey Traffic Signs 2 Helmet 6 Not Applicable a Signals, or Officer 7 Entering/Exiling Parked/Standing 10 Improper Tum/Merge 3 Protective Pads Used 77 Other, Explain 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing (elbows, knees, shins, etc.) in Narrative lying, working, playing) 8Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown At cnrani rnoncresata SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCSE. ❑ 1 No 1 Test Not Given 2 Test 1 Blood 2 Breath ❑ TEST RESULT. 1:1 ID DRUG USE I No ❑ Test Not Given Bloodrrative ❑ Yes 3Test Givetva n 77 Explain COMPLETED 3 Test Give e g 82 8 Unknown Tested NOthher, 88 88 known n, if Tested n Na1 Explain 88 UPosndir SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 2 DELRAY BEACH FIRE RESCUE DB 21010855 BETHESDA HOSPITAL 77 Other, Explain in Narrative 88 Unknown ADDITI NAL PASSENGERS PERSON ]VEHICLE #[IAME DATE OF BIRTH I INJ I SEX LOC: S R O EJECT HU EP I ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nat Tn spp W 2 EMS 3 Lew EMartemen n ( . EVW, In N.- BE Unenmm ❑ JEMS PERSON # VEHICLE 77 DATE OF BIRTH INJ I SEX I LOC: S I R 0 1 EJECT I HU EP ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO t Nak Trap PMW 2 EMS 3 Law Enldcarcnl 77 kXM1er, Exgain in N.- W Univpwn ❑ HSMV 90010 S 4 8 Page of_ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21.1728 87073133 Vehicle 1 driver stated " I was traveling south bound on SRA1A and collided with a ramp off the rear of an auto transport carrier. I did not see the ramp of the auto transport carrier because it did not have lights displayed at the time of the crash." Vehicle 2 driver Stated " My auto transport carrier was stopped on SRA1A in the south bound lane. I was delivering a vehicle when Vehicle 1 collided with one of the ramps off the rear of my auto transport carrier causing a steel plate to strike my foot. " Veh. 1 struck Veh, 2 causing damage to the driver side ramp of Veh 2 and injury to the driver of Veh. 2's foot, who was standing at the rear of the ramp when contact was made. Veh.1 air bags deployed. Veh.1 was disabled due to damage and towed away. The driver of Veh.2 was transported to Bethesda hospital for treatment. There were no other reported injuries at the time of the crash. Veh. 2 was driven away from the accident scene by an alternate driver. Update report completed when Law Enforcement learned of injuries after the crash date. ADDITIONAL PASSENGERS PERSON #rEHICLE # AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 2 ANTHONY NT CE PUGLIESE 1/2/1947 3 1 3 1 1 1 3 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3145 N OCEAN BLVD GULFSTREAM FL 33321 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd Tnnep— 2 EMS S law Enl>cpnerE r 0—. E�"i I N"mtive. unb 1 PERSON # EHICLE # ME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 3 r [CATHERINEDEGABRIELLE 9/16/1956 2 2 1 2 1 1 3 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 23668 MIRABELLA CIR N BOCA RATON FL 33433 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd Tran—W 2 EMS S law Enbrcenad P Other, EvWn m 1 Nan"Uw, Un,_ ❑ tD•NAL "OLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. POLICE DEPARTMENT I(PD) 758 OFFICER O-NEAL,A GULF STREAM POLICE DEPARTM HSMV 90010 S 5 8 Page of DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT 21-1728 1 87073133 NOT TO SCALE VEH 1 VEH 2 HSMV 90010 S 6 8 Page of _ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21-1728 87073133 ADDITIONAL PASSENGERS PERSON EHICLE #[AME DATE OF BIRTH INJ SEX LOC: S R 0 EJECT HU EP ABD RS IV 41 LRA KAy PUGLIESE 11/15/1960 4 2 3 2 1 3 4 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3146 N OCEAN BLVD GULFSTREAM FL 33483 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Na Tnewpp 2 EMS Slaw Enlaonnntl n 011wr, E�4 M N�rta1Ne SS Unbwwn 1 ❑ PERSON # VEHICLE # [AME DATE OF BIRTH INJ I SEX I LOC: S IR 0 1 EJECT HU EP ABID RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd TnnaW. 2 EMS Slaw EnlarcemaM ]] OINer, E ii in NamtlNa BB UnWwwn ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 1768 OFFICER O'NEAL,A GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S 7 B Page of_ VEHICLE # 2 Check if Commercial �/ ReporlrtgAgencyCaseNumber ❑ HSMV Crash Report Number 21-1728 87073133 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check f Permanent VIN 2 Parked Motor Vehicle 3 Working Vehicle 1 ❑ P1100399 IL Registration 0 1GNSCGKC5GR416428 Hit and Run 1 No YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 4 EST. AMOUNT 2 Yes 2021 VOLVO KENTUCKY AUTO CARRIER WHITE - WHI 2 Functional 88 Unknown $5,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: a VEHICLE REMOVED BY 1. Rotation 2. owner Request 77 ARACHAS GROUP LLC CPS7259M 1 No 2 Yes SECOND DRIVER - TAT 3. Driver 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑� CURRENT ADDRESS CITY & STATE ZIP CARRY $63 BITTERSWEET DR NORTHBROOK IL 60062 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check If Permanent VIN YEAR MAKE LENGTH AXLES One: 786892ST [L Registration R 1T9VC5323MW296135 2021 KAIS 30 2 TralW LICENSE NUMBER STATE REGISTRATION EXPIRES Check ff Permanent VIN YEAR MAKE LENGTH AXLES Two; Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ a ❑ ❑ ❑ ❑ Al & BANYAN RD 10 35 1 2 HAZ. MAT, RELEASED 1No THAZ. MAT. PLACARD 1No NUMBER CLASS Area of Initial Impact Most Damaged Area 21 21 2 Yes 1 ❑ 2 Yes 1 ❑ 3 4 5 6 3 4 5 6 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 8 1 15 16 17 6 20 Windshield 20 CARRIER NAME US DOT NUMBER MOTOR 14 9 21 Trailer 21 14 9 CARRY TRANSPORTATION INC 1868131 13 12 11 0 13 12 11 0 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER 863 BITTERSWEET DR. NORTHBROOK IL 60062 (630) 289-4410 Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 1 Two -Way, Not Divided 20 17 Cargo Van (10,000 Ibs (4,536 kg) or less) 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 2 Two -Way, Not Divided, with a Continuous Left Turn Lane 2 Single -Unit Truck (2-axle and k9). Cannot Classify 1 Passenger Car 18 Motor Coach )) Ibs or more in van (seats for 9-15 3 Two -Way, Divided, Unprotected more than it Truck or more axles) occupants, including diner) 3 Single -Unit Truck e a 10 occupanBus/Larts, 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling er 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 (bobtail) 5 Truck Tractor (bobtail) 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier occupants, including driver) 6 Truck Tractor/Semi-Trailer 8 Bus than 10,000 Ibs (4,536 kg)) 77 Other, Explain in Narrative 5 One -Way Trafficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 13 All Terrain Vehicle (ATV) 77 Other, Explain in Narrative Trailer Type 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type 13 dal Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 1 Interstate Cartier Box Container Chassis 4 Saddle Mount/trailer 77 Other, Explain in 3 HopperVan[Entame Chassis 10 ❑ 10 4 Hopper 14 Vehicle Towing 5BoatTreiler Narrative 1 2 Intrastate Cartier SPcle-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 7 House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 2 Bus 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision Comm 1 10,000lbs (4,536 kg) or less 8 Dump (4,536 kg) or less not 1 Overtum/Rollover GVWR/GCWR 2 2 10,001-26,000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 3 More than 26,000lbs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 12 Log 88 Unknown 14 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 19 Impact Attenuator/Crash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 30 Concrete Traffic Barrier Vehicle Use 20 Bridge Overhead Structure 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 31 Other Traffic Barrier 21 Bridge Pier or Support Sequence of Events 8 Ran into Water/Canal 13 Animal 32 Tree (standing) 22 Bridge Rail ❑ 9 Other Non -Collision 14 Motor Vehicle in Transport 23 Culvert 33 Utility Pole/Light Support u 2❑nd 15 Parked Motor Vehicle 34 Traffic Sign Support 4 [40.46 Sequence of Everts only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 2 Yes 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd 4th ❑ ❑ 42 Ran Off Roadway, Right 43 Ran Off Roadway, Left Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 18 Other Non -Fixed Object building,tunnel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects Roadway Grade 45 Cross Centerline 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Straight Ahead 13 Stopped in Traffic This Vehicle ❑ ❑ 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest Roadway Alignment 13 5 Tuming Right 16 Leaving Traffic Lane 9 Railway Crossing 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including Device 4 Lights Windshield 5 Sag (bottom) 1 2 Curve Right ❑ ahead, 10 Making U-Tum 88 Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Function 77 Other, Explain in 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative Of Motor Vehicle 2 Farm Vehicle 10 Fire Truck 15 Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown FEI 3 Police Shuttle Bour 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 8 8 Page of _ FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH LONG FORM Q SHORT FORM ❑ UPDATE ❑ TOTAL # OF VEHICLE SECTION(S) 2 (shaded Areas) 2 TOTAL # OF PERSON SECTION(S) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TOTAL # OF NARRATIVE SECTION(S) 1 TALLAHASSEE, FL 32399-0537 CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 08/27/2021 10:02 PM 1 08/27/2021 121-1728 187073133 CRASH IDENTIFIERS COUNTY CODE __] PLACE OR CITY OF CRASH IME REPORTED TIME DISPATCHED 06 ICITYCODE ICOUNTYOFCRASH PALM BEACH GULF STREAM CITY LIMITS 10:04 PM 1 10:04 PM TIME ON SCENE IME CLEARED SCENE CHECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist COMPLETED I 2 10:07 PM 11:59 PM 2 Law Enforcement ROADWAY INFORMATION (CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY AT STREET ADDRESS # AT LATITUDE AND LONGITUDE SRAtA 3500 BLOCK In 26.496914 -80.053473 AT FEET 5 MILES N S Ji E W ._� © AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY BANYAN RD OR FROM MILEPOST# Road System Identifier 1 Interstate 4 County 3 2 U.S. 5 Local 3 State 6 Tumpike/Toll 7 Forest Road 8 Private Roadway 9 Parking Lot 77 Other, Explain in Narrative Type of Shoulder 1 Paved 2 Unpaved 3 Curb a Type of Intersection 1 Nof at Intersection 2 Four -Way Intersection 3 T-Intersection 4 Y-Intersection 5 Traffic Circle 6 Roundabout 7 Five -Point, or More 77 Other, Explain in Narrative CRASH INFORMATION (CHECK IF PICTURES TAKEN) Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact ❑ 1 Daylight 4 2 Dusk 5 Dark -Not Lighted 6Darit-Unknown 4 Flog, Smog, Smoke 5 SleefMail/ 1 Freezing Rain 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction 3 Dawn 4 Dark -Lighted Lighting 77 Other, Explain in 6 Blowing Sand, Soil 1 8 Water 1 Directly Involved 6 Rear to Side Narrative Dirt 1 Clear (standing/moving) 3 Yes, School Bus 1 Front to 7 Rear to Rear Rear77 88 Unknown 7 Severe Crosswinds 2 Cloudy 77 Other, Explain in 1 Dry 77 Other, Explain in 2 Wet Narrative Indirectly Involved Other, Explain in Narrative 2 Front to Front 3 Rain Narrative 4 Ice/Frost 88 Unknown 3 Angle 88 Unknown First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overtum/Rollover 10 Pedestrian 19 Impact Attenuator/Crash 30 Concrete 2 Fire/Explosion 11 Pedalcycle Cusion 31 Other Traffic Barrier Location 1 On Roadway 3 Immersion 12 Railway vehicle (train, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 1$ ❑ 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 Cargo/Equipment 13Animal 22 Bridge Rail 34 Traffic Sign Support 4 Median First Harmful Event Loss or Shift 14 Motor Vehicle in 23 Culvert 35 Traffic Signal Support 6 Gore 6 Fell/Jumped From Transport 24 Curb 36 Ohter Post, Pole or 7 Separator within Interchange Motor Vehicle 15 Parked Motor Vehicle 25 Ditch Support 8 In Parking Lane or 1 No 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 2 Yes Object Equipment 27 Guardrail Face 38 Mailbox 8 Ran int Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 9 Outside Right-of-way 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Ob'ect First Harmful Event Relation to Contributing Circumstances: Road g Wom, Travel -Polished Surface Contributing Circumstances: Environment 77 ❑ Junction 5 Railway Grade Crossing 14 Entrance/Exit Ramp 77 icy, snow, slush, etc.) ❑ ❑ ❑ 10 Road Surface Condition (wet, 11 Obstruction in Roadway ❑ ❑ ❑ 1 Non -Junction 15 Crossover- Related 16 Shared -Use of Path or Trail 12 Debris 1 None 13 Traffic Control Device 1 None 5 Animals in Roadway () � y 2 Intersection 17Acceleration/DcelerationLane 4 Work Zone (construction/ Inoperative, Missing or p g Obscured 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway maintenance/utility 14 Non -Highway Work 3 Physical Obstruction(s) Narrative 4 Driveway/Alley Access 77 Other, Explain in Narrative 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 4 Glare 88 Unknown Related 88 Unknown 7 Rut, Holes, Bumps 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone Law Enforcement in Work 1 Before the First Work Zone 1 Lane Closure Zone 1 No 2 Yes Warning Sign 2 Advance Warning Area ❑ 3 Transition Area 2 Lane Shift/Crossover R/Crossover 3 Work on Shoulder or Median 4 Intermittent or Moving Work ❑ 1 No ❑ 2 Yes 1 No 2 Officer Present 88 Unknown 4 Activity Area 77 Other, Explain in Narrative 88 Unknown 3 Law Enforcement Vehicle 5 Termination Area Only Present WITNESSES NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE NON VEHICLE PROPERTY DAMAGE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME 0 (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE VEH. # PER # PROPERTY DAMAGE -OTHER THAN VEH. EST. AMT. OWNER'S NAME (CHECK IF BUSINESS) ADDRESS CITY & STATE ZIP CODE HSMV 90010 S 1 8 Page of _ VEHICLE # 1 Check if Commercial Re porting Agency Case Number HSMV Crash Report Number ❑ 21-1728 87073133 1 VehiGe m Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN 2 Parked Motor VehiGe 1 3 Working Vehicle HHRH74 FL Registration 0 1GNSCGKC5GR416428 Hit and Run 1 N0 YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 1 EST. AMOUNT 2 Yes 2016 CHEV UT UTILITY WHITE - WHI 2 Functional 88 Unknown $25,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 2 VEHICLE REMOVED BY 1. Rotation 2. Request 1 TRAVELERS CASUALTY INS. 3N940e31BA 1 No 2 Yes ZUCCALA 3. D iv^ err 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP PHILIP ANDREW PIKE 1 4100 SANATUARY LN BOCA RATON FL 33431 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One; Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ M ❑ ❑ ❑ ❑ IAIA 135 35 2 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 02 03 2 Yes ❑ 2 Yes ❑ 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 Unknown 88 Unknown 1 15 16 17 6 19 Overturn 19 1 15 16 17 8 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 12 11 10 13 12 11 1 D MOTOR CARRIER ADDRESS CITY T777F ODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 16 1 Vehicle 10,000 Ibs or less Placarded 8 Tractorrrdple 1 Two -Way, Not Divided 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 17 Cargo Van (10,000 lbs (4,536 kg) or less) 2 Two -Way, Not Divided, with a Continuous Left Turn Lane 2 Single -Unit Truck (2-axle and kg), Cannot Classify more than )) 10 van (seats for 9-15 Ibs (or 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected occupanBus/Larts, in 3 Single -Unit Truck (3 or more axles) occupants, including driver) it Truck e a more 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 Truck Tractor (bobtail) Trucks (more Median Barrier occupants, including driver) 7 Motor Home 20 Medium/HeMedium/Heavy5 4,536 k 8 Bus than 10,000Ibs 9)) ( 6 Truck Tractor/Semi-Trailer 77 Other, E lain in Narrative 5 One -Way Traffiuway Explain Truck Tractor/Double Truck e 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trail@r Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer Cargo Body Type Comm/Non-Commercial 2 Tandem Semi Trailer 9 Towed Vehicle TRAILER 1 TRAILER 2 dal 3 Tank Trailer 10 Auto Transport 13 1 Interstate Carrier Box Container Chassis 4 Saddle MounVirailer 77 Other, Explain in 3 HopperVan/Entame Chassis 5 Boat Trailer Narrative ❑ ❑ ❑ 4 Hopper 14 Vehicle Towing 2 Intrastate Cartier 5Pote-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 7 House Trailer 1 No Cargo 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 2 Bus 1 10,000 Ibs (4,536 kg) or less 8 Dump (4,536 kg) or less not Comm 1 Overtum/Rollover GVWR/GCWR 4 2 10,001-26.000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard ❑ 2 Fire/Explosion 3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not Applicable 11 Garbage/Refuse Narrative 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 14 19 Impact AttenuatorlCrash Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 20 Bridge Overhead Structure 31 Other Traffic Barrier Sequence of Events 8 Ran into Water/Canal 13 Animal 21 Bridge Pier or Support 32 Tree (standing) 9 Other Non -Collision e in Transport 22 Bridge Rail 33 Utility Pole/Light Support 1 14 Motor Vehicle Culvert ❑ 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 14 ❑ [40-6 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 1 No brake failure, etc.) 2 Yes 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 3rd 4th 42 Ran Off Roadway, Right ❑ ❑ 43 Ran Off Roadway, Left Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic This VehiCla ❑ 3 Turning Left 14 Slowing ❑ 1 Level 2 Hillcrest Roadway Alignment 4 Backing 15 Negotiating a Curve 8 Flashing Signal 1 None 1 5 Turning Right 16 Leaving Traffic Lane 1 9 Railway Crossing 1 3 Uphill 1 No Controls Device 2 Brakes 13 Wheels 6 Changing Lanes 17 Entering Traffic Lane 4 School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill ❑ 1 Straight 1 8 Parked 77 Other, Explain in Narrative 10 Person (including Device 4 Lights (head, Windshield 5 Sag (bottom) 2 Curve Right 10 Making U-Tum 88 Unknown 5 Traffic Control Flagman, Officer, signal, tail) 15 Mirrors 3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Function 77 Other, Explain in 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative 1 2 Farm Vehicle of Motor Vehicle 10 Fire Truck 15 Charter/1'our Bus 7 Yield Sign 9 Exhaust System Safety Chains 88 Unknown 3 Police 11 Farm Labor Transport 16 Shuttle Bus 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative 8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIVLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER 1 PHILIP ANDREW PIKE 316.1926(1) CARELESS DRIVING Al PKOTP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER jj VALENTIN IVANOVIC NOVIK H 316.194 1 A 3 5( )( ) IMPROPER STOP WITHIN INTERSECTION Al PKOVP PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 2 6 Page of_ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 21-1728 87073133 1 Driver VEHICLE* NAME PHONE NUMBER CheckIf 2 Non -Motorist 1 ❑ 1 673-4248 Recommend LJ 3 Passenger PHILIP ANDREW PIKE (561) Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 4100 SANCTUARY LN BOCA RATON FL 33431 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 04/07/1967 2 Female 88 Unknown P2006616712700 FL 04/07/2025 2 Possible 3 Non -Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements tat Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 B 3 C 1 No Contribution Action 26 Ran off Roadway Time of 1 Carelss or 27 1-51 ❑22 Operated MV in 9Disregarded other Traffic Crash 5 E/Operator 2 No Negligent Manner 1 Apparently Normal 6 E/Oper-Rest 3 No Re . Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road q 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 111(sick) or Fainted 6 Improper Turn29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehide Steering 6 Seizure, Epilespsy, Blackout 1 Not Distracted (explain in narrative) 2nd 10 Followed too Closely 7 Physically Impaired 88 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided: 8 Emotional (depression, oiled : 4th angry, disturbed, etc.) 2 Electronic Communication (outside the vehicle, explain 12 Drove too Fast for Conditions to Wind, Slippery MV e Devices (cell phone, etc. in narrative 1 13 Ran StopSin 9 Under the Influence of g Object, Non -Motorist in 1 Medicetions/Dru s/Alcohol 3 Other Electronic Device ) ❑ g r 6 Texting 15 Improper Passing Roadway, etc. (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, 77 Other, Explain in Narrative 88 Unknown 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action DRIVER VISION OBSTRUCTIONS 1 Vision Not Obscured 5 Load on Vehicle 9 Smoke 1 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER ❑ 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems DRIVER OR PASSENGER ❑ 1DOT-Compliant ❑ 1 Yes 3 IRS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: 2 Other Helmet 3 Not Applicable 1 NotApplicable (non -motorist) FLOCAIION: Seat Row Other G) 1 1 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left 1 Not Applicable 4 Shoulder Belt Only Used 1 Front Air Bag Deployed g 2 Midde 2 Sleeper Section of Truck Cab 5 Deployed -Other 5 Lap Belt Only Used 2 Second 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used -Type Unknown g (knee, air belt, etc.) 1 Not Ejected ❑ 1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Faring 77 Other 3 Third 4 Unenclosed Cargo Area 3 (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System - Rear Facing 5 Trailing Unit 1 ❑ narrative 3 Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- Partial) 3 Deployed -Front 7 Deployed Curtain 10 Child Restraint Type Unknown 88 Unknown 88 Unknown ( y 4 DeployedSide 88 Deployment yp trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown NON- N n-Idotorlat Description 1 Pe�estnan ❑ Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk ❑ 11 2 Other Pedestrian (wheelchari, person in a 9 Median/Crossing Island 2 Intersection - Unmarked Crosswalk 6 In Roadway — Other (working, building, skater, pedestrian conveyance, etc. 10 Drivewa Access y 3 Intersection - Other4 Midbiock - Marked Crosswalk 11 Shared -Use Path Trail playing, etc.) se or 1 Crossing Roadway 3 Bicyclist 4 Other Cyclist Raoy (e.g., 12 Non-Trafficway Area 2 Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location shoulder, median) 77 Other, Explain in Narrative 3 Walking/Cyding Along 6 Bicycle Lane g Going to or from School (K-12) (parked, etc.) 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside (iWorking in Trafficway 6 Occupant of a Non -Motor Vehicle p j ) adjacent to travel lane (incident response) Transportation Device Non -Motorist Action rcuma nces 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist tat 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 Dart/Dash or adjacent to travel lane) Unknown 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs 1 None Safety Equipment 5 Lighting 2 Helmet 6 Not Applicable 3 Protective Pads Used ❑ Signals, or Officer 7 Entering/Exiting Parked/Standing t0Improper Tum/Merge znd ❑ Vehicle 11 Improper Passing Improperly 77 Other, Explain (elbows, knees, shins, etc.) in Narrative 5 In Roadway (standing, lying,working. 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking g, playing) 4 Reflective Clothing (jacket, 88 Unknown 9 Not Visible dark clothing, p ❑ 6 Disabled Vehicle Related (working ( g, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: stNotGive 2 Test Refused n ❑ 1 Blood 2 Breath 7Urine ❑ EST RESULT. 1 PENDING ❑ ❑ _RUG sG USE: ❑ 2 Test n ❑ 1 Blood Urine ❑ 1 Positive ❑ 2 Yes 3 Test Given 7 Other. Explain 2 COMPL TED 3 Test Gvfen� 73 7 Other, 3 Pend ng 88 Unknown 88 Unknown, rfTested in Narrative 88 UNKNOWN 8 Unknown 88 Unknown, If Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGER PERSON # VEHICLE # AME DATE OF BIRTH I INJ SEX LOG : S R O EJECT J HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NO TaroporteC 2 EMS 3 Lew Enrorcemen177 Other, E, MN in Narrative B8 U.1- ❑ PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R 0 EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NO T-p- 2 EMS 3 taw Edmcmrottl 77 Other, E g l m in Narrative M Unbtoim ❑ HSMV 90010 S 3 8 Page of PERSON # 5 Reporting Agency Case Number HSMV Crash Report Number 21-1728 87073133 1 Driver VEHICLE* NAME PHONE NUMBER Check if ❑ 2 Non -Motorist F-2 ] I Recommend 3 Passenger VALENTIN IVANOVICH NOVIK Driver Re -exam CURRENT ADDRESS (Number and Street) CITY 8 STATE ZIP CODE 2050 OLEANDER BLVD APT 3 104 FORT PIERCE FL 34950 DATE OF BIRTH SEX: 1 MaleF11 DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) ❑ 02/17/1959 2 Female 88 Unknown 2 Possible 6 Non -Traffic Fatality 3 Non -Incapacitating DL Type Required Endorsements 1 A 2 B 3 C ❑ 4 D/Chauffeur 1 Yes 5 E/Operator 2 No 6 E/Oper-Rest 3 No Req. Endorsement 7 None Distracted By 4 Other Inside the Vehicle ❑Driver (explain in narrative) 1 Not Distracted 5 External Distraction 2 Electronic Communication (outside the vehicle, explain Devices (cell phone, etc. in narrative) 3 Other Electronic Device 6 Texting (navigation device, OVD player) 7 Inattentive 88 Unknown tat Drivers Actions at Time of Crash ❑1 No Contribution Action 2 Operated MV in Carelss or 26 Ran off Roadway 27 Disregarded other Traffic Negligent Manner Sign 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 4 Improper Backing Markings 6 Improper Turn 29 Over-Correcting/Over Steering 2nd 10 Followed too Closely 11 Ran Red Light 30 Swerved or Avoided: Due Drove too Fast for Conditions to Wind, Slippery Surface, MV, ❑12 13 Ran Stop Sign Object, Non -Motorist in 15 Improper Passing Roadway, etc. 17 Exceeded Posted Speed 31 Operated MV in Erratic, 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action 3rd 4th Condition At Time of Crash 1 Apparently Normal 3 Asleep or Fatigued 5 III (sick) or Fainted 6 Seizure, Epilespsy, Blackout 7 Physically Impaired 8 Emotional (depression, angry, disturbed, etc.) 9 Under the Influence of Medications/Drugs/Alcohol 77 Other, Explain in Narrative 88 Unknown _i vision rvoT voscurea 5 Load on Vehicle 9 Smoke I ❑ 2 Inclement Weather 6 Building/Fixed Object 10 Glare DRIVER OR PASSENGER 3 Parked/Stopped Vehicle 7 Signs/Billboards 77 All Other, Explain 4 Trees/Crops/Bushes 8 Fog in Narrative Helmet Use (HU) Eye Protection (EP) Restraint Systems DRIVER OR PASSENGER 1 DOT -Compliant 1 Yes ❑ (RS) Motorcycle Helmet ❑ ❑ 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 NotApplicable (non -motorist) Seat Row Other (LOC) 3 No Helmet 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 1 Left1 Not Applicable 1 Front Air Bag Deployed De to ed 4 Shoulder Belt Only Used 2 Midde 2 Sleeper Section of Truck Cab 2 Second 5 Deployed -Other 5 Lap Belt Only Used 3 Right 3 Other Enclosed Cargo Area Third Ejection (EJECT) (knee, air belt, etc.) 6 Restraint Used -Type Unknown 77 Other3 4 Unenclosed Cargo Area 1 Not Ejected 2 Ejected, Totally 1 Not Applicable 7 Child Restraint System •Forward Facing (explain in 4 Fourth 5 Trailing UnitCombination ❑ 2 Not Deployed 8 Child Restraint System -Rear Facing narrative) 88 Unknown 77 Other Row 6 Ridingon Motor Vehicle Exterior non- g8 Unknown ( 3 Ejected, Partially 3 Deployed -Front 7 Deployed -Curtain 4 Deployed -Side 88 Deployment 9 Booster Seat 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown n n-MOIonsT uescnpuon 1 Pe non-motonIn Location AT l rme oT crasn 8 Sidewalk rnor ro craan estnan 2 Other Pedestrian (wheelGrad person in a 5 building, skater, pedestrian conveyance, etc. ❑ 1 Intersection -Marked Crosswalk ❑ 2 Intersection -Unmarked Crosswalk 77 3 Intersection - Other4 Midblock -Marked Crosswalk 9 MediaNCrossing Island 10 Driveway Access Y [Hycuon 5 Walking/Cyclingon Sidewalk 6 In Roadway —Other (working, playing, etc.) 3 Bicyclist 11 Shared -Use Path or Trail 1 Crossing Roadway 7 Adjacent to Raodway 4 Other Cyclist 4 Midblock -Marked Crosswalk 5 Travel Lane -Other Location 12 Non-Trafficwa Area Y 2 Waiting to Cross Roadway (e.g., shoulder, median) 5 Occupant of Motor Vehicle Not in Transport 6 Bicycle Lane 77 Other, Explain in Narrative 88 Unknown 3 Along 8 Going to or from School (K-12) (parked, etc.) 6 Occupant of allon-Motor Vehicle 7 shoulder/Roadside Roadway with Traffic (in or Roadway with Traffic adjacent to travel lane) (iWorking in way Transportation Device Non-MotorlSt ACtionsicircurnstances 4 Walking/Cycling Along (incident response) 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 1st 1 ❑ 2 Dart/Dash or adjacent to travel lane) 88Unknown 3 Failure to Yield Right-of-Way 1 None Safety Equipment 5 Lighting 2 Helmet 4 Failure to Obey Traffic Signs Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 6 Not Applicable 3 Protective Pads Used 77 Other, Explain z 5 In Roadway Impropedy (standing, Vehicle 11 Improper Passing ( elbows, knees, shins, etc.) in Narrative lying,working, g, playing) 8 Inattentive (talking, satin etc Wrong -Way g g g, g ) 12 Wron Wa Riding or Walking 4 Reflective Clothing (jacket, 88 Unknown 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative backpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAC SUSPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: ❑ 2 Test Refused Givenest Not ❑ 3 UrineBlood Breath ❑ TEST RESULT ❑ ❑ 1 DY sG USE. 2 Test Not dGiven Test ❑ 3 Ter, ❑ 1 Positive ❑ 2 Yes 3 Test Given 77 er,2Explain 2 COMPLEGTED ❑ 3 Test Given 3 Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 Unknown 88 Unknown, if Tested Explain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 2 DELRAY BEACH FIRE RESCUE BETHESDA HOSPITAL 77 Other, Explain in Narrative 68 Unknown DB 21010856 ADDITIONAL PASSENGERS PERSON ]VEHICLE # [AME DATE OF BIRTH I INJ SEX LOC: S R 0 EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 NM Tnn.por . 2 EMS 3 law Ent— ] 0EM bin in Nsmthre W Unkrpwn ❑ 1EMSAGENCY PERSON # VEHICLE # AME DATE OF BIRTH INJ I SEX I LOC: S I R O EJECT I HU I EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nol T—p— ] EMS S law Enforcement ]] gNer, E�bin In NanMive W Unknown ❑ HSMV 90010 S 4 8 Page of — Reporting Agency Case Number HSMV Crash Repot Number NARRATIVE 21.1728 1 87073133 Vehicle 1 driver stated " I was traveling south bound on SRA1A and collided with a ramp off the rear of a auto transport carder. I did not see the ramp of the auto transport carrier because it did not have lights displayed at the time of the crash." Vehicle 2 driver Stated " my auto transport carrier was stopped on SRA1A in the south bound lane. I was delivering a vehicle when Vehicle 1 collided with one of the ramps off the rear of my auto transport carrier causing a steel plate to strike my foot. " Veh. 1 struck Veh. 2 causing damage to the driver side ramp of Veh 2 and injury to the driver of Veh. 2's foot, who was standing at the rear of the ramp when contact was made. Veh.1 air bags deployed Veh.1 was disabled due to damage and towed away. The driver of Veh.2 was transported to Bethesda hospital for treatment. There were no other reported injuries at the time. Veh. 2 was driven away from the accident scene by an alternate driver. ADDITIONAL PASSENGERS PERSON #rEHICLE # AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 2 ANTHONY NT°E PUGLIESE 1/2/1947 1 1 3 1 1 1 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3145 N OCEAN BLVD GULFSTREAM FL 33321 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nat TninW. 2 EMS 3 taw Enfonxm"nt 7 aI , EVW to N.—tl WUnlawwn 1 ❑ PERSON # EHICLE #�CATHERINE AME DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 3 r DEGABRIELLE 9116/1956 1 2 1 2 1 1 2 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 23668 MIRABELLA CIR N BOCA RATON FL 33433 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 Nd Trv.WM 2 EMS 3 L"w EMaraerm�R 71 tJlfbr, EvWin in '1 Nvntiw BB Unlarown ❑ ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 1758 POLICE DEPARTMENT OFFICER O'NEAL,A GULF STREAM POLICE DEPARTM (PD) HSMV 90010 S 5 8 Page of_ DIAGRAM REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 21-1728 1 87073133 HSMV 90010 S NOT TO SCALE SRAlA AREA OF IJPACT aANVAN Ro 6 8 Page of_ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 21-1728 87073133 ADDITIONAL PASSENGERS PERSON # VEHICLE # E DATE OF BIRTH INJ SEX LOC: S R O EJECT HU EP ABD RS 4 1 [LAM AURA KAY PUGLIESE 11/15/1960 1 2 3 2 1 4 3 CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE 3146 N OCEAN BLVD GULFSTREAM FL 33483 SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 N Tw po 2 EMS 3 Law Enfmoenwr n Olin, E.*in in 1 N� 88 Uriivrown ❑ PERSON ]VEHICLE # AME DATE OF BIRTH I INJ I SEX I LOC: S IR 0 EJECT HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 1 "Trwlpa 2 EMS 3 Law EnfacameM n IX , E pl in N—m 88 Unbwmi ❑ JEMS ADDITIONAL VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER REPORTING OFFICER ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT. 758 OFFICER O'NEAL,A GULF STREAM POLICE DEPARTM POLICE DEPARTMENT (PD) HSMV 90010 S 7 B Page of_ VEHICLE # 2 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 21-1728 1 87073133 1 Vehicle in Trans ort VEHICLE LICENSE NUMBER STATE P REGISTRATION EXPIRES Check If Permanent VN 2 Parked Motor VehiGe 2 3 Working Vehicle P1100399 IL Registration 0 1GNSCGKC5GR416428 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST. AMOUNT 1 No 1 Disabling 4 Minor 2 Yes 1 2021 VOLVO AUTO CARRIER WHITE - WHI 2 Functional 88 Unknown 3 None 88 Unknown 4 1$5,000.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1 1. Rotation to Damage: 2. Owner Request ARACHAS GROUP LLC CP37269088 t No 2 Yes E SECOND DRIVER -TAT 3. Driver 1 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) Fw-1 CURRENT ADDRESS CITY & STATE ZIP CARRY 863 BITTERSWEET DR NORTHBROOK IL 60062 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: 785892ST IL Registration a 1T9VC5323MW296135 2021 KENT. 30 2 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check If Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ M ❑ ❑ ❑ ❑ A1A Sr BANYAN RD 10 35 1 2 HAZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 2 Yes E 2 Yes E 2 3 4 5 6 7 21 18 Undercarriage 18 21 2 3 4 5 6 7 88 Unknown 88 Unknown MOTOR CARRIER NAME US DOT NUMBER 1 15 16 17 8 20 Windshield 20 1 15 16 17 8 CARRY TRANSPORTATION INC 1868131 14 13 12 11 10 g 21 Trailer 21 14 13 12 11 10 9 MOTOR CARRIER ADDRESS CITY STATE IZIPCODE PHONE NUMBER 863 BITTERSWEET DR. NORTHBROOK IL 60062 (630) 2894410 Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 1 Two -Way, Not Divided 1 Vehicle 10,000 Ibs or less Placarded 8 Tractorfrnple 20 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 (4,536 kg) or less) Continuous 17 Cargo Van (10,000 Ibs 2 Two -Way, Left Turn Lane 4 Not Divided, with a 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected more than 10,000 Ibs (4,536 kg)) 10 Bus/Large van (seats for 9-15 (painted >4 feet 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (P )Median 3 Single -Unit Truck (3 or more axles) occupants, including driver)4 Truck Pulling Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 il bt b t Tractor (bobtail) 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier 5 Truckoccupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Trafficway 7 Truck Tractor/Double Truck 88 Unknown 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 12 MoPPed 77 Other, Explain in Narrative Trailer Type 13 All Terain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 dal 3 Tank Trailer 10 Auto Transport 13 tame Chassis 4 Saddle Mount/Trailer 77 Other, Explain in 3 HopperVantEn Box Container Chassis ❑ 1 Interstate Carrier 10 ❑ 10 4 Hopper An Vehicle Towing 1 5 Boat Trailer Narrative 2 Intrastate Carrier 5Poie-Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 4 Not in Commerce/Other Truck 7 House Trailer 1 No Cargo 7 Flatbed (vehicle 10,000 Ibs 1 10,000 Ibs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not Most Harmful Event Non -Collision Comm 2 10,001-26,000lbs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard t Overturn/Rollover GVWR/GCWR 3 More than 26,000Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Immersion on 4 Not Applicable 11 Garbage/Refuse Narrative 3 Immersion 12 Log 88 Unknown 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency 15 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 19ImpactOverhead /Crash Cushion 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 20 Bridge Overhead Structure 31 Other Traffic Barrier 21 Bridge Pier or Support ❑ Sequence of Events 8 Ran into Water/Canal 13 Animal 32 Tree (standing) 22 Bridge Rail 1 9 Other Non -Collision 14 Motor Vehicle Culvert e in Transport 33 Utility Pole/Light Support 1st 2nd 15 Parked Motor Vehicle34 Traffic Sign Support 15 ❑ [4046 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1 No 40 equipment Failure (blown tire, Equipment 25 Ditch 36 Other Post, Pole, or Support 2 Yes brake failure, etc.) 17 Struck By Falling, Shifting Cargo or 26 Embankment 37 Fence 88 Unknown 3rd 4th 41 Separation of Units Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox ❑ ❑ 42 Ran Off Roadway, Right Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 43 Ran Off Roadway, Left 18 Other Non -Fixed Object building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centedine 1 Straight Ahead 13 Stopped in Traffic This VehlCla ❑ ❑ Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing 1 Level 4 Backing 15 Negotiating a Curve 1 8 Flashing Signal 1 None 2 Hillcrest 8 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sigh 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 5 Sag (bottom) 1 2 Curve Right 10 Making U-Tum 88 Unknown Device 5 Traffic Control Flagman, Officer, 4 Lights (head, Windshield signal, tail) 15 Mirrors3 Curve Left 11 Overtaking/Passing Guard, etc.) Signal 6 Steering 16 Truck Coupling Special Function Other, Explain in On 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ 2 Farm Vehicle 10 Fire Truck 15 CharterRNarrative our Bus 7 Yield Sign 9 Exhaust System Safety Chains 1 of Motor Vehicle 3 Police 11 Farm Labor Transport 16 Shuttle Bus 88 Unknown 10 Body, Doors 77 Other, Explain in 7 Taxi 12 School Bus 17 Farm Labor Bus 11 Power Train Narrative8 Military 13 Transit/Commuter Bus 88 Unknown 12 Suspension 88 Unknown VIOLATIONS PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER PERSON # NAME OF VIOLATOR FL STATUTE NUMBER CHARGE CITATION NUMBER HSMV 90010 S 8 8 Page of_ SWORN S'I'ATF,iviEN'I' FOR •TRAFFIC CRASH REPORT INFORMATION iVlotor vehicle crash information is confidential and exempt from disclosure liar a period of 60 daysafter the date the crash report is filed. §316.000(3)(c) Fla. Slats. (2003). Obtaining confidential information by someone who knows they are not entitled to do so is a I•clony violation. The undersigned r ue 9 firllo«' ig crash report (date/location/parties): $ :2 7-2 / of o' S� The 1111clersigneAf states that he she of he organization they represent qualify for immediate disclosure of'the crash report according to the exemption checked below and does swear or affirm that information contained in a crash report matte confidential by statute will not be used for any commercial solicitation of accident victims, or knowingly disclosed to any third party for the purpose oi'such solicitation, during the period of time that the information remains confidential. ❑ I tun a party involved in the crash. 1 /b �� I am a legal representative to a party involved in the crash: Fla. Bar No Olt Immediate Relative (relation) OR Written Authoritv from immediate relatitie, copy attached. ❑ I am a licensed insurance agent to a path' involved in the crash, their insurer or insurers to which they applied for insurance coverage, Fla. License No. ❑ I am a person under contract to provide claims or underwriting information to a qualifying insurance company, identified as: ❑ I am a p►•usecutirtg authority, Fla. Bar No. ❑ I represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices or a free newspaper of* general circulation, which qualifies under the statute Name of Radiorrelevision Station, Newspaper ❑ I represent a local, state or federal agency that is authorized by law to have access to these reports. ❑ I represent a Victim Service Program, as defined in §316.003(8 4), Florida Statutes. Name of Program: & /1311siness Represented L/ Address (Area Code) Telephone Number City, State, Gip Code Sla is of Florida, Counlp of A/rYea 1 QD ,� Sill) n o (or aniruud) nd subscribed before n1c this t dad of(!l l�+fi44kr, 2(IjC/, in fors I r+, 5S, ion ljpc of Ld. prodoccd: t v --E LAINNE F. TORR Notary PLbiic - State ofI•rin 'I`y n► la WyL%nt111U$ittiplFflfl!&14y Siguahn•c of Nat:y f•uhlie n ('crlilitd am •. forrenlcnl ur 5orcee. through National Notao orrerlional O ficer ►•►vers is •r ;e ► otcrgraphic identification, prouf of status or identification that demonstrates qualifications to access this information were reviewed by agency employee, on this day of , 200_ I IS\I \ .941)10 tttr.. 08%115)