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HomeMy Public PortalAboutPRR 22-2900 Renee Basel From:Enrique Mesa <quique1201@gmail.com> Sent:Monday, July 11, 2022 10:35 AM To:Renee Basel Subject:Accident Report You don't often get email from quique1201@gmail.com. Learn why this is important \[NOTICE: This message originated outside of the Town of Gulfstream -- DO NOT CLICK on links or open attachments unless you are sure the content is safe.\] Good morning. I would like to request an accident report. Case number 221264 (Rafael Centeno). Can you please let me know if we have to fill out any forms? Thank you in advance for your help. 1 Sworn Statement to Obtain Traffic Crash Report Information Pursuant to Section 316.066(2), Florida Statutes, motor vehicle crash information is confidential and exempt from disclosure for a period of 60 days after the crash report is filed. Obtaining confidential information when not entitled to do so is a felony violation. The undersigned requests the following crash report (date/location/parties involved): 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 for any commercial solicitation of crash victims, or knowingly be disclosed to any third party for the purpose of such solicitation during the perio time that the information remains confidential. I am a party involved in the crash. ❑ 1 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 which they applied for insurance coverage. Florida License Number: ❑ 1 am a person under contract to provide claims or underwriting information to a qualifying insurance company, identified as: ❑ 1 am a prosecuting authority. Florida Bar Number: ❑ 1 represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices or a free newspaper of general circulation, as defined in Section 316.066(2)(b), Florida Statutes. Name of radio/television/newspaper: ❑ 1 represent a local, state or federal agency that is authorized by law to have access to crash reports. Name of local/state/federal agency: ❑ I represent a Victim Services Program, as defined in Section 316.003(8), Florida Statutes. Name of Program: _Printed Na. Signature 71-511 2?3 05c1 Telephone Number with Area Code State of Florid county of 1 Agency/Business/Represented Address City, State, Zip Code Sworn ,(,or affirmed) and subscribed before me by means of ical prgsencor ❑ online notarization this j day of 20�by�� Pe'sonaliv Ki iown 171 or Prod ced Identification (ID) Fr fvne ID Pro Pr A p°m DIANA DELORENZO o n Notary Public, State of Florida /5 U-U- y �irr��s9a�l►�It,Eo ary Name natur otary Public or A Certified Form HSMV 94010 (revised March 2020i Law Enforcement or Correctional Officer 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 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 06/20/2022 1 11:40 AM 06/2012 1 221264 187073142 CRASH IDENTIFIERS COUNTY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHIN[TIME REPORTED TIME DISPATCHED ICITYCODE CITY LIMITS 06 44 PALM BEACH GULF STREAM 11:40 AM 11:40 AM TIME ON SCENE [ME CLEARED SCENE CHECK IF REASON (If Investigation NOT Complete) Notified By: 1 Motorist COMPLETED , I 11:41 AM 12:30 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 BLUEWATER COVE 2910 26.492031 -80.061992 AT FEET MILES N S E W ATIFROM INTERSECTION WITH STREET, ROAD,HIGHWAY OR FROM MILEPOST# ❑ ❑ ❑ ❑ Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 8 Private Roadway 9 Parking Lot 1 Interstate 4 County 77 Other, Explain in 6 2 U.S. 5 Local 1 Paved 2 Unpaved 1 Nof at Intersection 6 2 Four -Way Intersection 7 y 1 3 T-Intersection 77 Roundabout Five -Point, or More Other, Explain in Narrative 3 State 6 Turnpike/loll Narrative 3 Curb 4 Y-Intersection CRASH INFORMATION (CHECK IF PICTURES TAKEN) Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact ❑ 1 Daylight 1 2 Dusk 5 Dark -Not Lighted 6bark-Unknown 1 4 Flog, Smog, Smoke 5 Sleet/Hail/ Freezing Rain 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 77 5 Sideswipe, Opposite Direction 3 Dawn Lighting 6 Blowing Sand, Soil 6 8 Water 1 Directly Involved 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Narrative 1 Clear Dirt (standing/moving) 3 Yes, School Bus 7 Rear to Rear 1 Front to Rear 88 Unknown 2 Cloud Y 7 Severe Crosswinds 1 Dry Other, Explain in Indirectly Involved 77 Other, Explain in Narrative 2 Front to Front 3 Rain 77 Other, Explain in 2 Wet Narrative N g8 Unknown Narrative 4 Ice/Frost 88 Unknown 3 Angle First Harmful Event Non -Collision Collision Non -Fixed Object Collision with Fixed Object First Harmful Event 1 Overtum/Rollover 10 Pedestrian 19 ImpactAttenuator/Crash 30 Concrete 2 Fire/Explosion 11 Pedalcycle Cusion 31 Other Traffic Barrier Location 1 On Roadway 3 Immersion 12 Railway vehicle (Vain, 20 Bridge Overhead Structure 32 Tree (standing) 2 Off Roadway 14 4 Jackknife engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 3 Shoulder 5 Cargo/Equipment 13 Animal 22 Bridge Rail 34 Traffic Sign Support 2 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 7 Thrown or Falling 16 Work Zone/Maintainance 26 Embankment 37 Fence Zone 1 No 2 Yes 1❑ Object 8 Ran int Water/Canal Equipment 27 Guardrail Face 38 Mailbox 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 buildinq, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Object First Harmful Event Relation to Contributing Circumstances: Road g Worn, Travel -Polished Surface Contributing Circumstances: Environment 77 ❑ Junction 5 Railway Grade Crossing 14 Entrance/Exit Ramp 14 1 icy, snow, slush, etc.) ❑ ❑ ❑ 10 Rnod 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 Animal(s) in Roadway 2 Intersection 17 Acceleration/Dceleration Lane 4 Work Zone (construction/ Inoperative, Missing g or Obscured 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related 18 Through Roadway 9 Y 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 q 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 F3 Warning Sign ingArea 2Advance Warning 4 3 Transition Area 2 Lane Shift/Crossover Work on Shoulder or Median 4 Intermittent or Moving Work 77 1 No 2 2 Yes 1 No 1 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 ❑ (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 7 Page of _ VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number 1 221264 87073142 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check Permanent VIN 2 Parked Motor Vehicle 3 3 Working Vehicle Registration ❑ 160339 Hit and Run 1 No YEAR MAKE MODEL STYLE BACKHOE/LOADE COLOR DAMAGE: 1 Disabling 4 Minor 2 EST. AMOUNT 2 YesEll 2022 DOOSA DL220 ORANGE - ONG ional gg Unknown $2,5U0.00 88 Unknown R 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER d due amage: r1l, 1 El VEHICLE REMOVED BY 1. Rotation r Request ACORD 6061277478 2 Yes OWNER 3. D ivn er2. 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY & STATE MICHAEL JOHN CZAJKOWSKI 12666 HEADWATER CIRCLE WELLINGTON FL [z3L414 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES if Permanent VIN YEAR MAKE LENGTH AXLES One: Registration Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES JCheck Check if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration r VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING Fv_1 ❑ ❑ ❑ ❑ ❑ 12910 BLUEWATER COVE 5 5 0 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 09 09 2 Yes ❑ 2 Yes ❑ 3 4 2 5 6 3 4 5 6 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 1 15 19 Overturn 19 16 17 8 20 Windshield 20 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 12 1110 13 12 11 10 MOTOR CARRIER ADDRESS CITY T77—FODE PHONE NUMBER 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 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 21 17 Cargo Van (10,000 Ibs 2 Two -Way, Not Divided, with a 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify (4,536 kg) or less) Continuous Left Turn Lane ❑ more than 10,000lbs (4,536 kg)) 10 Bus/Large van (seats for 9-15 1 Passenger Car 18 Motor Coach 3 Two -Way, Divided, Unprotected 3 Single -Unit Truck (3 or more axles) occupants, including driver) 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling Trailers) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 5 Truck Tractor (bobtail) 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrieroccupants, including driver) 6 Truck Tractor/Semi-Trailer 8 Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Trafficway 77 Other, Explain in Narrative 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown gg Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer Cargo Body Type 2 Tandem Semi Trailer 9 Towed Vehicle 13 Intermodal Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 10 Auto Transport 1 Interstate Carrier ❑ ❑ 4 Saddle Mount/Trailer 5 Boat Trailer 77 Other, Explain in ❑ 3 Van/Enclosed Box Container Chassis 4 Hopper 14 Vehicle Towing Narrative 2 Intrastate Carrier 5 Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 4 Not in Commerce/Other Truck 7 House Trailer CargoPole-Tra Tank 1 No Cargo 6 Cargo Tank 15 Not Applicable 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 2 Bus 1 10,000 Ibs kg) or less 8 Dump kg) less not Comm 000Iti displaying HI placard 4 2 10,001-26,000Ibs (4,536-11,793kg) 9 Concrete Mixer displaying ❑ 1 Overturn/Rollover GVWR/GCWR 3 More than 26,000 Ibs It 1,793kg) 10 Auto Transport 77 Other, Explain in xp 2 Fire/Explosion 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 14 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 29 Cable Barrier Emergency 19 Impact /Crash Cushion 30 Concrete Traffic Barrier Vehicle Use OvAtterhead 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 1 ❑ 9 Other Non -Collision 14 Motor Vehicle in Transport 33 Utility Pole/Light Support 23 Culvert 1st 2nd 15 Parked Motor Vehicle [40-46 Sequence of Events only] 16 Work Zone/Maintenance 34 Traffic Sign Support 24 Curb 35 Traffic Signal Support 1 No 14 14 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 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, 16 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 Centerline Roadway Grade 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic 3 Turning Left 14 Slowing This Vehicle ❑ 1 Level 2 Hillcrest 4 Backing 15 Negotiating a Curve 4 5 Turning Right 16 Leaving Traffic Lane 1 8 Flashing Signal 1 None 9 Railway Crossing Roadway Alignment 1 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane 1 No Controls 2 Brakes 13 Wheels 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 (head, Windshield 3 g (bottom) 5 Sa2 Curve Right ❑ 10 Making U-Turn 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 9 Ambulance 14 Intercity Bus 77 Other, Explain in 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative Motor Vehicle 2 Farm Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign 88 Unknown 9 Exhaust System Safety Chains of 3 Police E S 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 2 7 Page of_ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 221264 87073142 1Driver VEHICLE# NAME PHONE NUMBER Check'rf u 2 Non -Motorist 1 ❑ 2 Recommend 3 Passenger RAFAEL ENRIQUE CENTENO (764) 273-0593 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 2384 NW 34TH RD FUTCREEK FL 33066 DATE OF BIRTH SEX. 1 Male ❑ DRIVERS LICENSE NUMBER STATE EXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 None 5 Fatal (within 30 days) 08/15/1945 2 Is 68 Unknown C535725452950 FL 08/15/2022 2 Possible 6 Non -Traffic Fatality 3Non-Incapacitating DRIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At 1 No tMa � in 9Disrega Disregarded other Traffic ❑ Crash ribution Action 26 Ran off Roadway TIme f 1 r Carelss or 27 ❑ 5 ElOperator 2 Nos Negligent Manner 6 E/Oper-Rest 3 No Re 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 1 Apparently Normal q .Endorsement 7 None 4 Improper Backing Markings 3 Asleep or Fatigued 6 Improper Turn 29 Over-Correcting/Over 5 III (sick) or Fainted Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 2nd 1 Not Distracted 8 Emotional (depression, 1 5 External Distraction 11 Ran Red Light 30 Swerved or Avoided : Due ( P 2 Electronic Communication outside the vehicle, explain 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) ( P to Wind, Slippery Surface, MV, Devices (cell phone, etc, 13 Ran Sto Sin 9 Under the Influence of in narrative P 9 Object, Non -Motorist in 3 Other Electronic Device 6 Textin 15 Improper PassingMedications/Drugs/Alcohol Roadway, etc. 1:1 (navigation device, DVD player) 7 Inattentive 17 Exceeded Posted S eed 77 Other, Explain in Narrative P 31 Operated MV in Erratic, 88 Unknown 88 Unknown 21 Wrong Side of Wrong Way Reckless orAgreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contribufing 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) Restraint Systems 3 1DoT-Compliant ❑ 1 Yes (RS) DRIVER OR PASSENGER El SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) FOCATION: Seat Row Other ) 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 Might 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.) 77 Other 3 Third 1 Not Ejected 1 Not A licable 7 Child Restraint System -Forward Facing 4 Unenclosed Cargo Area 1 pP 6 Deployed - (explain in 4 Fourth 2 Ejected, Totally 2 Not Deployed Combination 8 Child Restraint System - Rear Facing 5 Trailing Unit E narrative 3 E Ejected, 9 Booster Seat 77 Other Row 6 Ridingon Motor Vehicle Exterior non- 1 3 Deployed -Front 7 Deployed -Curtain 88 Unknown 88 Unknown Partially 4 Deployed -Side 88 Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown ❑N n-Motorist Description 1 Perpestnan ❑ Non -Motorist Location At Time of Crash 8 Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cyclingon Sidewalk 2 Other Pedestrian (wheelchari, person in a 9 Median/Crossing Island 2 Intersection - Unmarked Crosswalk 10 Driveway Access 6 In Roadway —Other (working, building, skater, pedestrian conveyance, etc. 3 Bicyclist 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path or Trail playing, etc.) 1 Crossing Roadway ' 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non-Tratficway Area 2 Waiting to Cross Roadway 7 Adlacent to y (e.g., 5 Occupant of Motor Vehicle Not in Transport ian)Rao 5 Travel Lane - Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along shoulder, median) 6 Bicycle Lane 8 Going to or from School (K-12) (parked, etc.) 88 Unknown or g Working in Trafficway 7 shoulder/Roadside Roadway with la 6 Occupant of a Non -Motor Vehicle travel ) adjacent to travel lane) (incident response) Transportation Device Non -Motorist Acons rcums ances 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 1st ❑ 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 DarVDash or adjacent to travel lane) 88 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 10 Improper Tum/Merge end ❑ Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) in Narrative 5 In Roadway Improperly (standing, lying, working, playing) 8 Inattentive (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 ALCOHOUDRUG/EMS SUSPECTED ALCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT: ALCOHOL USE: 2 Test Refused Test Not ❑ Breath 1 Blood 3 Urine ❑ 1 PENDING ❑ EST RESULTRUG 2 USE: ❑188 Given1 Test Not Test ❑ lood ❑ rine I Positive ❑ 2 Yes 3 Test Given77 Other, er,2Explain 2 COMPLETED 3 Test Give enact 77 other, 3 Pend ng 88 Unknown 88 Unknown, if Tested in Narrative 88 UNKNOWN 88 Unknown 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 PASSENGERS PERSON # 1 VEHICLE # [AME DATE OF BIRTH INJ I SEX I LOC: S I R O EJECT J HU EP I ABD I 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 t NW Transported 2 EMS 3 t Enlacement 77 Oltrer. EYPlaln in Narrative 88 unknown ❑ PERSON # VEHICLE # [AME DATE OF BIRTH I INJ I SEX I LOC: S R 1 O EJECT J HU EP I ABD I 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 t NW Transported 2 EMS 3 Law Enlorcc 77 Oltwr. Exptaln in Nam — el unknwm ❑ JEMS HSMV 90010 S 3 7 Page of_ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 221264 87073142 The following traffic event happened in the area of 2910 Bluewater Cove in the Town of Gulf Stream, Florida. The area is a construction site with a designated dirt roadway to direct dump trucks into the work area. The driver of V-2 was using the designated dirt roadway to access the work site. V-1(Front end loader) was being operated by the driver(Mark Harris) who was fired by the V-1 owner prior to my arrival and had left the work site. The driver of V-1 was backing up in a designated work area and backed out of his work area onto the designated dirt roadway. The driver of V-2 stopped in the roadway and activated his vehicle horn to alert the driver of the backing V-1. As the driver of V-1 continued backing the driver of V-2 continued activating his horn to alert the driver to stop. Other persons on the work site including the V-1 owner yelled at the driver of V-1 to stop. The driver of V-2 was unable to back away and V-1 struck V-2 in the right front fender area. V-1 sustained damage to the left rear area and left rear light of the vehicle. The driver of V-2 was not injured and subsequently drove his vehicle from the work site. The owner of V-1 stated he would take responsibility for any damage to V-2. ADDITIONAL PASSENGERS PERSON # VEHICLE # [AME DATE OF BIRTH INJ I SEX LOC: S R O 1 EJECT HU EP I ABD IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE t NM Trannpprtetl 2 EMS S law Enforcement 77 al r, Explain in SOURCE OF TRANSPORT TO MEDICAL FACILITY ❑J Na '-88 Unknown EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO PERSON # VEHICLE #[IAME DATE OF BIRTH INJ I SEX I LOC: S I R O 1 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 ME DICAL FACILITY TRANSPORTED TO 1 NM T—pWe 2 EMS 3 Law Enforcement ]] ONer. Explain in Narrrti+e 88 Unknown ❑ 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. 755 OFC. R. WILSON GULF STREAM POLICE DEPARTM POLICE DEPARTMENT I (PD) HSMV 90010 S 4 7 Page of _ REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER DIAGRAM 221264 1 87073142 NOT TO SCALE HSMV 90010 S 5 7 Page of VEHICLE # 2 Agency Case Number Check if Commercial ❑ HSMV Crash Report Number 264 87073142 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE FReporting ISTRATION EXPIRES rf Permanent3 VIN 2 Parked Motor V oe Working Vehicle 1Check P0304G FL 31/2022 Registration ❑ 1FTYY95BOTVA00923 Hit and Run 1 No YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 2 EST. AMOUNT 2 Yes LLI1996 FORD DUMP GREEN - GRN 2 Functional 88 Unknown $3,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER wed due Foo,Damage: 1 ❑ VEHICLE REMOVED BY 1. Rotation 2. Owner Request 77PROGRESSNE EXPRESS INS 03254118 2 Yes DRIVER 3. Drivero 4. Other, Explain in Narative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) LJ CURRENT ADDRESS CITY & STATE ZIP RAFAEL ENRIQUE CENTENO I 2384 NW 34TH RD COCONUT CREEK FL 33066 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 r VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ R1 ❑ ❑ ❑ ❑ 2910 BLUEWATER COVE 15 5 1 HAZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 03 18 2 Yes ❑ 2 Yes ❑ 3 4 2 5 6 3 4 5 6 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 1 15 19 Overturn 19 16 17 6 20 Windshield 20 1 15 16 17 B MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 12 1110 13 12 1110 MOTOR CARRIER ADDRESS CITY T777F ODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Traff]cway Commercial Motor Vehicle Configuration 16 (Sport) Utility Vehicle 1 Vehicle 10,000 Ibs or less Placarded 8 Tractorr-riple 1 Two -Way, Not Divided 5 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 77 17 Cargo Van (10,000 Ibs 2 Two -Way, Not Divided, with a 2 Single Truck GVWR kg), Cannot Classify (4,536 kg) or less) Continuous Left Turn Lane ❑ -Unit (2-axle and 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 3 Single -Unit Truck (3 or more axles) occupants, including driver) 2 Passenger Van 19 Other Light Trucks (10,000 Ibs (painted >4 feet) Median 4 Truck Pulling Trailers) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 Truck Tractor (bobtail) 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier occupants, including driver) occupants, 6 Truck Tractor/Semi-Trailer Bus than 10,000 Ibs (4,536 kg)) 5 One -Way Traffrcway 77 Other, Explain in Narrative 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown gg Unknown 12 Moped Trailer Ty 77 Other, Explain in Narrative Type 1 Single Semi Trailer 8 Pole Trailer 13 All Terain Vehicle (ATV) 88 Unknown 9 Towed Vehicle Cargo Body Type 2 Tandem Semi Trailer 2 13 dal oCh Comm/Non-Commercial TRAILER 1 TRAILER 3 Tank Trailer 10 Auto Transport 1 Interstate Carrier a ❑ El 4 Sddle Mount/Trailer 5 Boat Trailer tame r Chassis 3 Van/Enclosed Box Container 77 Other, Explain in ❑ 4 Hopper 14 Vehicle Towing Narrative2 Intrastate Carrier ❑ 6 Utility Trailer 5Pnle-Trailer Another Vehicle 88 Unknown7 3 Not in Commerce/Government 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 (4,536 kg) or less not 4 2 10,001-26,000Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Overturn/Rollover GVWR/GCWR 3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 4 Not Applicable 11 Garbage/Refuse Narrative3 Immersion 12 Log 88 Unknown 4 Jackknife Collision with Non -Fixed Object Collision Fixed Object 14 5 Cargo/Equipment Loss or Shift 10 Pedestrian 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 29 Cable Barrier Emergency 19 Impact Cushion 30 Concrete Traffic Barrier Vehicle Use OvAfterhead Structure 20 Bridge Overhead Structure 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 31 Other Traffic Barier 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 in Transport 33 Utility Pole/Light Support 23 Culvert 1st 2nd 15 Parked Motor Vehicle [40-46 Sequence of Events only] 16 Work Zone/Maintenance 34 Traffic Sign Support 24 Curb 35 Traffic Signal Support 1 No 14 16 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 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 18 Other Non -Fixed Object 28 Guardrail End 39 Other Fixed Object (wall, building, tunnel, etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects Roadway Grade 45 Cross Centerline 46 Downhill Runaway 1 Straight Ahead 13 Stopped in Traffic 3 Turning Left 14 Slowing This Vehicle ❑ ❑ 1 Level 2 Hillcrest 4 Backing 15 Negotiating a Curve 77 5 Tuming Right 16 Leaving Traffic Lane 1 8 Flashing Signal 1 None 9 Railway Crossing 1 3 Uphill Roadway Alignment 6 Changing Lanes 17 Entering Traffic Lane 1 No Controls 2 Brakes 13 Wheels Device School Zone Sign/ 3 Tires 14 Windows/ 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative ative 10 Person (including Device 4 Lights (head, Windshield 5 Sag (bottom) 3 2 Curve Right ❑ 10 Making U-Turn 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 9 Ambulance 14 Intercity Bus Explain in 6 Stop Sign 77 Other, 7 Wipers Trailer Hitch/ Narrative 2 Farm Vehicle 10 Fire Truck 15 Bus 7 Yield Sign Exhaust System Safety Chains 88 Unknownus ❑ of Motor Vehicle 1 3 Police 11 Farm Labor Transport 16 Shuttleuttle Bus Shuttle 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 6 7 Page of PERSON # 2 Reporting Agency Case Number HSMV Crash Report Number 221264 87073142 1 Driver VEHICLE # NAME PHONE NUMBER Check if E 2 Non -Motorist 1 3 Passenger ❑ 1 I MICHAEL JOHN CZAJKOWSKI (661) 718-3956 Recommend Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 12666 HEADWATER CIR WELLINGTON FL 33414 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER STATETEXPIRES INJURY SEVERITY (INJ) 4 Incapacitating 1 No 5 Fatal (within 30 days) 08/20/1963 2 Female se unknown C220550633000 FL 8/20/2028 2 Possible 6 Non -Traffic Fatality 3Non-Incapacitating DRIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 B 3 C — 1 N Contribution Action 26 Ran off Roadway Time f 1 9Disregarded other Traffic ❑ Crash No 2 Operated MV in El Negligent Manner Carelss or 27 5 E Operaorr 2 1 Apparently Normal 6 E/Oper-Rest 3 No Req. Endorsement 3 Failed to Yield Right -of -Way 28 Disregarded Other Road 3 Asleep or Fatigued 7 None 4 Improper Backing Markings 5 III (sick) or Fainted 6 Improper Turn 29 Over-Correcting/Over Driver Distracted By 4 Other Inside the Vehicle Steering 6 Seizure, Epilespsy, Blackout (explain in narrative) 2nd 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 5 External Distraction 11 Ran Red Light 8 Emotional (depression, 1 9 30 Swerved or Avoided :Due 2 Electronic Communication outside the vehicle, explain 12 Drove too Fast for Conditions 4th angry, disturbed, etc.) ( P Wind, Slippery Surface, MV, Devices (cell phone, etc. 13 Ran StopSinNon-Motorist❑ 9 Under the Influence of in narrative 9 Object, in O 3 Other Electronic Device 15 Improper Passin MedicationsOrugs/Alcohol 6 Telling9 Roadway, etc. navi ation device, OVD player) 77 Other, Explain in Narrative ( 9 P y ) 7 Inattentive 17 Exceeded Posted Speed 31 Operated MV in Erratic, P 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 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 ❑ 1 DOT -Compliant ❑ 1 Yes 3 (RS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: LOCATION: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Seat Row Other (LOC) 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 Sleeper Section of Truck Cab 5 Deployed -Other 5 Lap Bell Only Used 2 Might 2 Second 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used - Type Unknown g (knee, air belt, etc.) 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected 1 1 Not Applicable 6 Deployed- 7 Child Restraint System - Forward Facing (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- 3 Deployed -Front 7 Deployed -Curtain 88 Unknown gg Unknown ( Partially 4 Deployed -Side 88 Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown NON- N n-Motorist Description 1 Pedestrian ❑ Non -Motorist Location At Time of Crash g Sidewalk ❑ Action Prior to Crash 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk Island 2 Other Pedestrian (wheelchari, person in a 9 Median/Crossing 2 Intersection -Unmarked Crosswalk 6 In Roadway —Other (working, building, skater, pedestrian conveyance, etc. 10 Driveway Access 3 Intersection - Other4 Midblock - Marked Crosswalk 11 Shared -Use Path Trail playing, etc.) se or 1 Crossing Roadway 3 Bicyclist 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non-Trafficway Area 2 Waiting to Cross Roadway 7 Adjacent to Raodway (e.g., 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location 77 Other, Explain in Narrative 3 Walking/Cycling Along shoulder, median) 6 Bicycle Lane 8 Going to from School (K-12) (parked, etc.) 88 Unknown Roadwaywith Traffic in or in 7 shoulder/Roadside 9 Working in Trafficway 6 Occupant of a Non -Motor Vehicle adjacent to travel lane) / (incident response) Transportation Device n Non -Motorist osActions/Circumstances 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist Ftst ❑ 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 DarttDash or adjacent to travel lane) 88 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 Officer7 Entering/Exiting Parked/Standing 101mproperTuMMerge Vehicle 11 Improper Passing 77 Other, Explain (elbows, knees, shins, etc.) in Narrative 9�nd 5 In Roadway Impropedy (standing, 8 Inattentive g, g, ) g- y g g lying, working, playing) (talking, satin etc 12 Wrong -Way 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. LCOHOL BAC USPECTED DRUG TESTED: DRUG TEST TYPE: DRUG TEST RESULT. ALCOHOLUSE: N Test Not 2 Test Refused Given ❑ 1 Blood 2 Breath 77 0[88 ESTRESULT ❑ ❑DRUG USE: ❑ 1 2 [88188 Test No, Test v ❑ 1 Blood3 Urine❑ 1 Positive ❑ s 2 Yes 3 Test Given Other,, Explain COMPLETED 3 Test Genedn Other, 3 Pending 88 Unknown 88 Unknown, rfTested in Narrative UNKNOWN Unknown Unknown, rfTested 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 # VEHICLE # [AME DATE OF BIRTH INJ I SEX I LOC: S I R O EJECT J HU EP I 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 1 Not Tnn,, M 2 EMS 3 Law Enlorcement 77 ai— Exq in Narrative 88 Unknovm ❑ PERSON # 1 VEHICLE # AME 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 1 Not Tranap fta 2 EMS 3l Enforcemen177 Other. Explain In Narrative BB Unknavn ❑ JEMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO HSMV 90010 S 7 7 Page of