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HomeMy Public PortalAboutPRR 23-2969TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail November 8, 2023 Carlos Urrego [mail to: carlos.urregom@gmail.com] Re: GS #2969 (Request for Crash Report) I would like to request an accident report Crash Report 2023-0130769. Dear Carlos Urrego [mail to: carlos.urregom@gmail.com]: The Town of Gulf Stream has received your public records request dated November 6, 2023. You should be able to view your original request and response at the following link, as of January 8, 2024, because this record is confidential and exempt from disclosure for a period of 60 days after the crash report is filed per Florida Statue 316.066(2)(a): PRR 23-2969 (laserfiche.com) The police crash report you requested is attached to this e-mail. We consider this request closed. Sincerely, Reneé Basel, MMC Town Clerk Custodian of Records T014W OF GULF STREAM POLICE DEPARTMENT Requester's information: � � ec05, C1>Qc o r Name of Requester 632,V iA) J "64 AF 1I Street Address Pursuant to 316.066(2)(b), Fla. Stat. / //s /z D.�Z 3 Z6z3 ID 130 r,?69 Date of Request Telephone Number Reference # (Case/File Name) Fax Number -bc>CA P—A-mk) 3.-3V '6 ��,s1Usys'rz�cjo<vrC •vre4 City State Zip Email Address Crash information: 1012-46%Z02-2 :Z,>23013D r,76 I Date of Crash Crash Report # (if known) 5'Y6 i.L)t�/r� HT 11-4Y —ST2e-91 Ji Location of Crash 1 _ 0 yOrA C,D e0 Z-C�i 4,,v P 1,d J4 / re vc,4V Parties Involved Law Enforcement Agency Case # (FHP or other, if known) County (where crash occurred) SECTIONONE: • • Obtaining • • 60 Days of • Pursuant to § 316.066(2)(b), Fla. Stat., a crash report may be made available within 60 days of filing only to the following persons. Persons eligible to obtain a crash report during this 60-days period remain eligible once the 60 days has expired. Please select the option that best describes you (select one): EI am a party involved in the crash. ❑ I am the legal representative of (State / Bar number: (party involved in the crash) ❑ I am a licensed insurance agent of, an insurer of, or an insurer to which coverage has been applied for by, (party involved in the crash). (License number: ❑ I am a person under contract to provide claim or underwriting information for a qualifying insurer. (Name of insurer: ❑ I represent a victim services program. (Name of program: ❑ I represent a federal, state, or local governmental agency or am a private person or entity acting on behalf of such agency in carrying out its functions. (Agency name: ❑ I represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices under §§ 50.011 & 50.031, Fla. Stat. (Specified personal information must be redacted.) (Name of media organization: ❑ I am a third party acting on behalf of a person or entity listed above for disclosure of the crash report only to such person or entity. (Designate such person or entity by circling and completing the above selection.) (Name of person or entity: Under penalty of perjury, I swear (or affirm) that the foregoing answers are true and complete and that the requested report will not be used for commercial solicitation of crash victims or knowingly disclosed to any third party for purposes of such solicitation. Signature of Requester HSMV Form 94010 (Rev. 03/2023) Page 1 of 2 STATE OF +11K\ A COUNTY OF ?. CL\M Sworn to (or affirmed) and subscribed before me by means of 3 physical presence or ❑ online notarization this �_ day of (\N nl`o� , 20 -?,S by l��f ��J �PP�iI p who is ❑ personally known or ❑ produced identification. Type of identification produced: r. (NOT RY;AL) Signature of Nt��J JUNAE MCPHERSON h +fit, a= Notary Public -State of F]2025 v� wh a� << ,� Commission ; HH c 13(Print, Type or Stamp Commissioned Name of Notary Public) My Comm. Expires Cec 13'� My Commission expires: NOTICE: Section 316.066(3), Fla. Stat., provides criminal penalties against persons who knowingly obtain confidential crash reports they are not entitled to or who use such confidential information in violation of a filed written sworn statement. The statute also authorizes civil penalties against persons who knowingly disclose or use such confidential information for purposes not permitted under DPPA. iSECTION TWO: DPPA Certification for Obtaining Crash Report 60 Days or Later After Filing Pursuant to § 316.066(2)(f), Fla. Stat., crash reports may be made available 60 days after filing to any person or entity in accordance with any of the permissible uses listed in the federal Driver's Privacy Protection Act (DPPA), 18 U.S.C. § 2721(b) and pursuant to the act's resale and redisclosure requirements in 18 U.S.C. § 2721(c). Please select all permissible uses listed in 18 U.S.C. & 2721(b) for which you are eligible: ❑ For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or entity acting on behalf of a Federal, State, or local agency in carrying out its functions. ❑ For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non -owner records from the original owner records of motor vehicle manufacturers. For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only — El to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual. For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local court or agency or before any self -regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a Federal, State, or local court. For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals. For use by any insurer or insurance support organization, or by a self -insured entity, or its agents, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting. For use in providing notice to the owners of towed or impounded vehicles. For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection. El For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under 49 U.S.C. chapter 313. For use in connection with the operation of private toll transportation facilities. For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains. El For any other permissible use authorized in 18 U.S.C. § 2721(b). Provide documentation describing such use with specific citation to the respective provision of the federal act authorizing such use. Under penalty of perjury, I certify that I am entitled to receive the requested report according to the selected DPPA permissible use(s), that 1 understand I must comply with DPPA's resale and redisclosure requirements, and that the requested report will not be used for commercial solicitation of crash victims or knowingly disclosed to any third party for purposes of such solicitation. Signature of Requester HSMV Form 94010 (Rev. 03/2023) Page 2 of 2 FLORIDA TRAFFIC CRASH REPORT WAS DOT PROPERTY INVOLVED IN THIS CRASH? LONG FORM SHORT FORM UPDATE TOTAL # OF VEHICLE SECTION(S) 2 Isnaaed nraasl 3 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 IME OF CRASH DATE OF REPORT REPORTING AGENCY CASE NUMBER HSMV CRASH REPORT NUMBER 10/26/2023 112:20 PM 10/26/2023 120230130769 187073152 CRASH IDENTIFIERS COUNTY CODE ITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHIN IME REPORTED IME DISPATCHED 06 44 PALM BEACH GULF STREAM CITY LIMITS 12:29 PM 12:29 PM TIME ON SCENE IME CLEARED SCENE I CHECK IF COMPLETED ❑V 11:31 REASON (If Investigation NOT Complete) Notified By: 1 Motorist 12:29 PM 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 WRIGHT WAY 590 26.498980-80.057082 AT FEET MILES N S EW INTERWITH STREET, ROAD,HIGHWAY © �OR FROM MILEPOST# I 1:1 RSECTION OLD SCHOOL Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 8 Private Roadway 1 Not at Intersection 6 Roundabout 1 Interstate 4 County 9 Parking lot U.S. 5 Local 1 Paved 2 Unpaved 2 Four-Wa Intersection 7 Five -Point, or More Y 77 3 T-Intersection 77 Other, Explain in Narrative 11872 3 State 6 Turnpike/Toll 77 Other, Explain in Narrative 3 Curb 4 Y-Intersection RASH 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 4 Fog, Smog, Smoke 5 Sleet/Hail/ Freezing Rain 1 9 5 Oil 6 Mud, Dirt, Gravel 7 Sand 1 No 2 Yes, School Bus 4 Sideswipe, same direction 5 Sideswipe, Opposite Direction P PP 3 Dawn Lighting 6 Blowing Sand, Soil 1 8 Water ❑ 1 Directly Involved ❑ 6 Rear to Side 4 Dark -Lighted 77 Other, Explain in Dirt(standing/movin g) 3 Yes, School Bus 7 Rear to Rear Narrative 88 Unknown 1 Clear 2 Cloud 7 Severe Crosswinds Y 1 Dry 77 Other, Explain in Indirectly Involved 1 Front to 2 Front to Rear 77 Other, Explain in Narrative Front 77 Other, Explain in 3 Rain 2 Wet Narrative 88 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 10 verturn/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 15 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 8 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 Other 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 Object Equipment 27 Guardrail Face 38 Mailbox 9 Outside Right-of-way 1❑ 2 Yes 8 Ran into Water/Canal 17 Struck By Falling, Shifting 28 Guardrail End 39 Other Fixed Object (wall, 10 Roadside 88 Unknown 9 Other Collision Cargo 29 Cable Barrier building, tunnel, etc.) 88 Unknown 18 Other Non -Fixed Obiect First Harmful Event Relation to Contributing Circumstances: Road 9 Worn, Travel -Polished Surface Contributing Circumstances: Environment ❑ Junction 5 Railway Grade Crossing 10 Road Surface Condition (wet, ❑ [I F icy, snow, slush. etc.) 14 Entrance/Exit Ramp 11 Obstruction in Roadway El 1 Non -Junction 15 Crossover- Related 12 Debris 1 None 16 Shared -Use of Path or Trail 13 Traffic Control Device 1 None 5 Ammal(s) in Roadway 2 Intersection 17 Acceleration/Deceleration 4 Work Zone construction/ or Inoperative, Missing or Obscured 2 Weather Conditions 77 Other, Explain in 3 Intersection -Related Lane maintenance/utility 14 Non -Highway Work 3 Physical Obstruction(s) Narrative 4 Driveway/Alley Access 18 Through Roadway 6 Shoulders (none, low, soft, high) 77 Other, Explain in Narrative 4 Glare 88 Unknown Related 77 Other, Explain in Narrative 7 Rut, Holes, Bumps 88 Unknown Work Zone Related Crash in Work Zone Type of Work Zone Workers in Work Zone 1 Before the First Work Zone 1 Lane Closure 1 No 2 Yes Warning Sign 2 Advance Warning Area ❑ 3 Transition Area 2 Lane Shif /Crossover ❑ 3 Work on Shoulder or Median 4 Intermittent or Moving Work 1 No ❑ 2 Yes 88 Unknown 4 Activit Area Y 77 Other, Explain in Narrative 88 Unknown 5 Termination Area vvl I IVCJJCJ NAME ADDRESS CITY & STATE ZIP CODE ERIK BALDWIN 8980 211TH ST QUEENS VILLAGE NY 11427 NAME ADDRESS CITY & STATE ZIP CODE NAME ADDRESS CITY & STATE ZIP CODE N 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 # IROPERTY 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 ❑ 20230130769 87073152 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN 2 Parked Motor Vehicle 1 3 Working Vehicle 51CDLI FL 02/21/2025 Registration ❑ 1GBHK24K47E568516 Hit and Run YEAR MAKE MODEL STYLE COLOR DAMAGE: EST.AN�IOUNT 1 No 1 Disabling 4 Minor 2 Yes 1 007 CHEV SILVERADO ICKUP HITE - WHI 2 Functional 4 88 Unknown 3 None 88 Unknown 100.00 INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due VEHICLE REMOVED BY 1. Rotation to Damage: 1 2. Owner Request 3 GEICO 4564745752 1 No 2 Yes DRIVER 3. Driver ❑ 14. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ I CURRENT ADDRESS CITY & STATE ZIP OGENOR 0 DOMINIQUE 113 SW 14TH AVE DELRAY BEACH FL 33444 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 T EST. SPEED POSTED SPEED TOTAL LANES TRAVELING El El ❑� El El ElRIVATE DRIVEWAY 15 1 AZ. MAT. RELEASED HAZ. MAT. PLACARD NUMBER CLASS Area of Initial Impact Most Damaged Area 1 No ❑ 1 No ❑ 3 4 5 6 09 09 3 4 5 6 2 Yes 2 Yes 2 7 18 Undercarriage 18 2 7 88 Unknown 88 Unknown 1 15 16 17 8 19 Overturn 19 1 15 16 17 8 MOTOR CARRIER NAME US DOT NUMBER 20 Windshield 20 14 13 121110 9 21 Trailer 21 t4 13 1211 0 9 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration 1 Vehicle 10,000 Ibs or less Placarded 8 Tractorrrripie 16 (Sport) Utility Vehicle 5 1 Two-way, Not Divided for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 3 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 10,000 Ibs (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 Trailer(s) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 11 Bus (seats for more than 15 7 Motor Home 20 Medium/Heavy Trucks (more Median Barrier 5 Truck Tractor (bobtail) occupants, including driver) 6 Truck Tractor/Semi-Trailer 77 Other, Explain in Narrative 1 Bus than 1Q000 Ibs Vehicle kg)) 5 One-way Trafficway 7 Truck Tractor/Double Truck 11 Motorcycle 21 Farm Labor Vehicle 8 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) gg 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 3 Tank Trailer 10 Auto Transport 13 Intermodal ❑ ❑ A Vehicle Towing 4 Saddle railer 77 Other, Explain in El 3 Van/Enclosed Box Container Chassis 1 Interstate Carrier 5 Boat Trailerilex Narrative 4 Hopper 2 Intrastate Carrier 5Pote-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 lbs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not Most Harmful Event Non -Collision Comm 2 10,001-26,000 Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 1 Overtxplosi lover GVWR/GCWR 3 More than 26,000 Ibs(11,793kg) 10 Auto Transport 77 Other, Explain in 2 Fire/Explosion 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 6 Fell/Jumped From Motor Vehicle 11 Ped20 Bridge alcycle 19 Impact Overhead Su 31 Other Traffic Barrier /Crash Structure Cushion 30 Concrete Traffic Barrier Vehicle Use 7 Thrown or Falling Object 12 Railway Vehicle (train, engine) 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/Ligl Support 1 sl 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 14 ❑ [40-46 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 buildin tunnel 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 4 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 wheels 3 Uphill 6 Changing Lanes 17 Entering Traffic Lane Device 14 1 Device 4 School Zone Sign/ 3 Tires Wi Windows! 4 Downhill 1 Straight 8 Parked 77 Other, Explain in Narrative 10 Person (including 4 Lights (head, Windshield 5 Sag (bottom) 1 2 Curve Right 10 Making U-Tum 88 Unknown Flagman, Officer, 3 Curve Left 11 Overtaking/PassingOvertaking/Passing 5 Traffic Control Guard, etc.) signal, tail) 15 Mirrors Signal 6 Steering 16 Truck Coupling Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 77 Other, Explain in7 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 68 Unknown 3 Police 11 Farm Labor Transport i6 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 TransiUCommuter 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 20230130769 87073152 1 Driver VEHICLE# NAME PHONE NUMBER Check if ❑ 2 Non -Motorist 1 lml) 674-1313 Recommend 3 Passenger OGENOR DOMINIQUE Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE IP CODE 113 SW 14TH AVE DELRAY BEACH FL 723444 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER :]IFL TATETXPIRES INJURY SEVERITY (INJ)4 Incapacitating 1 None 5 Fatal (within 30 days) 02/21/1953 2 Female 88 Unknown D552640530610 21/2029 Possible 6 Non -Traffic Fatality 23 3Non-Incapacitating RIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd Condition At ❑ 1 A 2 B 3 C 1 1 No Time f 1 Acton 26 Ran off dolher 9D srega dedribution El Nos ❑4 NegligenittMa Manner Careless or 27 Traffic❑ Crash 5 E/Operators 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, Epilepsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 1 1 Not Distracted 5 Extemal Distraction 2nd 11 Ran Red Light 30 Swerved or Avoided: Due B Emotional (depression, 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. in 13 Ran StopSin 9 Under the Influence of 9 narrative Object, Non -Motorist in o 3 Other Electronic Device Medications/Drugs/Alcohol 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 21 Wrong Side of Wrong Way Reckless or Agressive 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) Restraint Systems DRIVER OR PASSENGER ❑ 1 DOT -Compliant 1 Yes 3 IRS) SEAT ROW OTHER Motorcycle Helmet 2 No Motor Vehicle Seating Position: CATION, 2 Other Helmet 3 NotApplicable 1 Not Applicable (non -motorist) Seat Row Other C)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 5 La B 2 Middle 2 Sleeper Section of Truck Cab 5 Deployed -Other P elt Only Used 2 Second 3 Right 3 Other Enclosed Cargo Area Ejection (EJECT) 6 Restraint Used - Type Unknown 3 Third g (knee, air belt, etc.) 77 Other 4 Unenclosed Cargo Area 1 Not Ejected 1 Not Applicable 7 Child Restraint System -Forward Facing 6 Deployed - (explain in 4 Fourth 9 2 Ejected, Totally 2 2 Not Deployed 8 Child Restraint System -Rear Facing 5 TrailingUnit 1Combination narrative) 77 Other Row 3 Ejected, 3 Deployed -Front 7 Deployed -Curtain 9 Booster Seat 88 Unknown 88 Unknown 6 Riding on Motor Vehicle Exterior (non- 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-M TORI T Non -Motorist Description 1 Pedestrian Non -Motorist Location At Time of Crash Action Prior to Crash 8 Sidewalk 1 Intersection •Marked Crosswalk 5 Walking/Cycling on Sidewalk 11-1 2 Other Pedestrian (wheelchair, person in a 9 Median/Crossin Island 9 2 Intersection 6 In Roadway —Other (working, building,skater, pedestrian conveyance, etc. P y -Unmarked Crosswalk 10 Driveway Access Y playing, etc.) 3 Intersection Other4 Midblock Marked Crosswalk 3 Bicyclist - - 11 Shared -Use Path or Trail 1 Crossing Y Roadwa 7 Adjacent to Raodway 4 Other Cyclist 4 Midblock - Marked Crosswalk (e.g., 12 Non-Traificway Area Wailing to Cross Roadway 5 ant of Motor Vehicle Not in Transport P 5 Travel Lane -Other Location 77 Other, Explain in Narrative Walking/CyclingAlon shoulder, median) 9 8 Going to or from School (K-12) 6 Bicycle Lane (parked, etc.) (parked, 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside (iWorking in ay 6 Occupant of a Non -Motor Vehicle djacent to travel lane) (incident response)) once Transportation Device Non -Motorist Ac ions rcums antes 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 3sL ❑ 1No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 2 Dart/Dash 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 Helmet 6 N Not Protective Pads Used Signals, or Officer ❑ ❑ 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge Ind Vehicle 11 Improper Passing 77 Other, Explain elbows, knees, shins, etc.) in Narrative 51n Roadway Improperly (standing, lying, working, playing) 8Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking Reflective Clothing (jacket, 88 Unknown 9 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative ackpack, etc.) lighting,etc. 88 Unknown on, pushing, leaving/approaching) ) ALCOHOL/DRUGIEMS SUSPECTED LCOHOL TESTED: ALCOHOL TEST TYPE: 0,LCOHOL BAC USPECTED RUG TESTED: RUG TEST TYPE: RUG TEST RESULT: ALCOHOL Cos USE: � Test Not 2 Test Refused Given lood 2 Breath 1 BUrine ❑ TEST RESULT: PENDING ❑ 1 RUG USE: 1 No Refused Given Test Not Test ❑ Blood Uri e❑ ❑ 2 Yes 3 Test Given77 Other,, Explain COMPLETED Yes Tes G ve 77 Other, 3 Pending 88 Unknown 88 Unknown, if Tested n Narrative 8 UNKNOWN 8 Unknown 8 Unknown, if Tested xplain 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 # JAME ATE OF BIRTH I INJ SEX ILOC:S IR O EJECT HU EP ABD I P.S CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY 1 Not TR pw 2EMS 3— Enfmremen(77 OTe E%gpm,n N..a N Unkr,vnn ❑ MS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO PERSON # EHICLE 11 JAME TE OF BIRTH IDA JINJ SEX ILOC:S IR O EJECT J HU EP I ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE OURCE OF TRANSPORT TO MEDICAL FACILITY 1 Not Tnnp dW 2 EMS 3 Lew Enkrcem 77 ONer, EMpipin'in Npn — N Unknown ❑ EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO HSMV 90010 S 3 7 Page of PERSON# 2 Reporting Agency Case Number HSMV Crash Report Number 20230130769 87073152 1 Driver VEHICLE # NAME NUMBER Check if ❑ 2 Non -Motorist 3 Passenger CARLOS A URREGO 7PHONE 34603 Recommend Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 632 NW 13TH ST APT 11 BOCA RATON FL 133486 DATE OF BIRTH SEX: 1 MaleF-11 DRIVERS LICENSE NUMBER TATE EXPIRES INJURY SEVERITY (INJ)4 Incapacitating 1 None 1 2 Female 2 Possible 5 Fatal (within days) 12/15/1969 88 Unknown 6Norr-Traffic Fat at 3 Non -Incapacitating Fatality DRIVER DL Type Required Endorsements 1st Drivers Actions at Time of Crash 3rd ❑1 A 2 B 3 C ❑ 1 No Contribution Action 26 Ran off Roadway Condition At ❑ 4 D/Chauffeur 1 Yes ❑ 2 Operated MV in Carelss or 27 Disregarded other Traffic ❑ Time of Crash 5 E/Operator 2 No Negligent Manner Sign 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 6 Seizure, Epilespsy, Blackout 4 Other Inside the Vehicle Stewing (explain in narrative) 10 Followed too Closely 7 Physically Impaired ❑ 2nd 1 Not Distracted 8 Emotional (depression, 5 External Distraction 11 Ran Red light 30 Swerved or Avoided :Due 4th 2 Electronic Communication outside the vehicle, explain 12 Drove too Fast for Conditions angry, disturbed, etc.) ( P Wind, Slippery Surface, MV, Devices (cell phone, etc. in narrative 13 Ran Stop Sin 9 Under the Influence of P 9 Object, Non -Motorist in O 3 Other Electronic Device 6 Textin 15Improper Passin ❑ Medications/Drugs/Alcohol 99 Roadway, etc. (navigation device, DVD player) 77 Other, Explain in Narrative 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 ❑ 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 1 DOT -Compliant ❑ 1 Yes (RS) DRIVER OR PASSENGER ❑ Motorcycle Helmet 2 No SEAT _R7W__7rR177__1 ❑ Motor Vehicle Seating Position ILOCATION. 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) Seat ROW Other LOC) 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 Front Air Bag Deployed 2 Midde 2 Slee er Section of Truck Cab 5 Deployed -Other 5 Lap Belt Only Used 2 Second p Right Ejection E 3 Ri 9 3 Other Enclosed Cargo Area 1 (EJECT) (knee, air belt, etc.) 6 Restraint Used -Type Unknown 77 Other 3 Third 4 Unenclosed Cargo Area i Not Ejected 1 Not Applicable y 7 Child Restraint System - Forward Facing 6 Deployed- in 4 Fourth 2 Ejected, Totally 2 Not Deployed 8 Child Restraint System -Rear Facing narrative) 5 Trailing UnitCombination 3 Ejected, 9 Booster Seat ❑ 77 Other Row 3 Deployed -Front 6 Ridingon Motor Vehicle Exterior non- 7 Deployed -Curtain 88 Unknown 88 Unknown Partially 4 Deployed -Side Deployment 10 Child Restraint Type Unknown trailing unit) 4 Not Applicable Unknown 77 Other, Explain in Narrative U 88 Unknown 88 Unknown NON -MOTORIST Noon -Motorist Description Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 Other ed 2 building, skater, pedestrian conveyance, etc. ❑2 Other Pedestrian (wheelchai, person in a 1 Intersection - Marked Crosswalk 5 Walking/Cycling on Sidewalk ❑ 9 Median/Crossing Island 10 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 Roadway —Other (working, 1 D Y 3 Bicyclist a 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway playing, etc.) 9 Y 4 Other Cyclist 4 Midblock -Marked Crosswalk 7 Adjacent to Raodway (e.g., 12 Non-Trafficway Area Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane - Other Location 77 Other, Explain in Narrative Walking/CyclingAlon shoulder, median) 6 Bicycle Lane P 9 8 Going to or from School (K-12) (parked, etc.) 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside 9 Working in Trafficwa y 6 Occupant of a Non -Motor Vehicle adjacent to travel lane) (incident response) Transportation Device on- o ons cons rrcums antes 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 1 No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative t8t ❑ 2 Dart/Dash or adjacent to travel lane) 1 3 Failure to Yield Right -of -Way 88 Unknown 4 Failure to Obey Traffic Signs Officer 7 Entering/Exiting Parked/Standing 10 Improper Turn/Merge 1 None Safety Equipment 5 Lighting Helmet 6 Not Applicable Protective Pads Used 77 Other, Explain ❑Signals, or 2nd 5 in Roadway Improperly (standing, Vehicle 11 Improper Passing elbows, knees, shins, etc.) in Narrative lying, working, playing) 8lnattentive (talking, eating, etc) 12 Wrong•Way Riding or Walking Reflective Clothing (jacket, 88 Unknown El 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative ackpack, etc.) on, pushing, leaving/approaching) lighting, etc.) 88 Unknown ALCOHOL/DRUG/EMS SUSPECTED LCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED DRUG TESTED: RUG TEST TYPE: RUG TEST RESULT: ALCOHOL USE: ❑ 1 Nc 1 1 Test Not Given ❑ 2 Test Refused 1 Blood 2 Breath ❑ Urine EST RESULT: ❑ 1 PENDING RUG USE: 1 1 No El Test Not Given ❑ Test Refused Blood ❑ Uine 1 Positive 2 Negative ❑ 2 Yes 3 Test Given 7 Other, Explain COMPLETED Yes 3 Test Given 7 Other, 3 Pending 88 Unknown 88 Unknown, if Tested n Narrative 8 UNKNOWN 8 Unknown 88 Unknown, if Tested xplain in Narrative 88 Unknown SOURCE OF TRANSPORT TO MEDICAL FACILITY EMS AGENCY NAME OR ID EMS RUN NUMBER EDICAL FACILITY TRANSPORTED TO 1 Not Transported 2 EMS 3 Law Enforcement 1 77 Other, Explain in Narrative 88 Unknown ADDITIONAL PASSENGERS PERSON # EHICLE # JAME ATE OF BIRTH JINJ IBEX LOC: S 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 Not Tan P.. 2 EMS 3 Lew Enhr.em 77 OMar, Explain,n Nana SS Unk ❑ PERSON # EHICLE # JAME ATE OF BIRTH INJI SEX ILOC:S IR O EJECT 1HU J EP JABD L CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE OURCE OF TRANSPORT TO MEDICAL FACILITY [:][MS t Nat TranapmbC2EMS 3Law Enbrm t77Omer,Explainin w_ N unaoown AGENCY NAME OR ID r EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO I HSMV 90010 S 4 7 Page of _ NARRATIVE Reporting Agency Case Number 20230130769 HSMV Crash Report Number 87073152 VEHICLE 1 AND VEHICLE 2 WERE PARKED IN DRIVEWAY, ON PRIVATE PROPERTY, AT 590 WRIGHT WAY. V2 WAS PARKED, UNOCCUPIED. V1 REVERSED, STRIKING V2 ON THE RIGHT REAR DOOR WITH LEFT REAR OF BUMPER. DRIVER OF V1 ULTIMATELY ADVISED OF RESPONSIBILITY. ADDITIONAL PASSENGERS ERSON # I EHICLE # AME DATE OF BIRTH I INJ SEX ILOC:S IR O EJECT HU EP ABD I RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE a�RCE OF TRANSPORT TO MEDICAL FACILITY lTanap — 2 EMS 3 Law Enfortement )) Other, Explain In Na _l BB Unknown ❑ EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO ERSON # I EHICLE # AME DATE OF BIRTH JINJ SEX LOC: S R O EJECT HU EP JABD L CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY Nol Trznapo— 2 EMS 3 Law Enforcement �� ONer, Explain In a .- 68 Unknown ADDITIONAL VIOLATIONS ❑ EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO 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 NAME DEPARTMENT OF DEPT. [TFICER [PYDPLE OICE DEPAR750 OFFICER ODD E SUTTON GULF STREAM POLICE DEPARTM ) HSMV 90010 S 5 7 Page of Hsn4V 90010 s 6 7 Page of VEHICLE # 2 Check if Commercial Reporting Agency Case Number ❑ HSMV Crash Report Number 20230130769 87073152 1 Vehicle in Trans ort VEHICLE LICENSE NUMBER STATE P REGISTRATION EXPIRES Permanent VIN 112/1512025 2 Parked Motor Vehicle 2 3 Working Vehicle Z391LZ JCheck'rf FL Registration ❑ PTDEPMAE4MJ138675 Hit and Run 1 No YEAR MAKE MODEL COLOR DAMAGE: 1 Disabling 4 Minor EST. AMOUNT 2 Yes 1 021 TOYT COROLLA SEDAN L ED - RED 2 Functional 4 88 Unknown 1,000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage: 1 VEHICLE REMOVED BY 1. Rotation 2. Request ❑ OCEAN HARBOR CASUALTY P020058026304 1 No 2 Yes PARKED 3. Dnverr 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP CARLOS A URREGO 632 NW 13TH ST APT 11 BOCA RATON FL 33486 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN YEAR MAKE LENGTH AXLES One: Registration ❑ Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES heck if Permanent VIN YEAR MAKE LENGTH AXLES Two: Registration ❑ VEHICLE N S E W Off -Road Unknown ON STREET, ROAD, HIGHWAY TEST. SPEED POSTED SPEED TOTAL LANES TRAVELING ❑ ❑ ❑ ❑ ❑� ❑ RIVATE DRIVEWAY 10 1 AZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area O5 05 2 Yes ❑ 2 Yes ❑ 2 3 4 5 6 7 18 Undercarriage 18 24546 88 Unknown 88 Unknown 1 15 16 19 Overturn 19 17 8 1 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 2t 14 13 1211 0 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration ❑ 16 (Sport) Utility Vehicle 1 17 Cargo Van Ibs 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 1 Two -Way, Not Divided 5 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 2 Two -Way, Not Divided, with a (10,000 (4,536 kg) or less) Continuous Left Turn Lane ❑ 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify more than 10,000 Ibs 4,536 k ( 9)) 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 Barrier occupants, including driver) 4,536 k 8 Bus than 10,000 Ibs 9)) ( 5 One -Way Trafficv✓ay 6 Truck Tractor/Semi-Trailer 77 Other7 Truck Tractor/Double Truck , Explain in Narrative P 11 Motorcycle 21 Farm Labor Vehicle 88 Unknown 88 Unknown 12 Mopetl 77 Other, Explain in Narrative Trailer Type 1 Single Semi Trailer 8 Pole Trailer 13 All Terrain Vehicle (ATV) 88 Unknown 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial TRAILER 1 TRAILER 2 3 Tank Trailer 13 cial 10 Auto Transport 1 Interstate Carrier ❑ ❑ 4 Saddle Mountlfrailer S Boat Trailer Container Ch 77 Other, Explain in ❑ 3 HopperVan/EnBox Container Chassis Narrativ77 Othee 4 Hopper 14 Vehicle Towing 2 Intrastate Carrier ❑ 6 Utility Trailer 5Pote-Trailer Another Vehicle 88 Unknown 3 Not in Commerce/Government 7 House Trailer 6 Cargo Tank 15 Not Applicable 1 No Cargo 4 Not in Commerce/Other Truck 7 Flatbed (vehicle 10,000 lbs 2 Bus Most Harmful Event Non -Collision 1 10,000 Ibs (4,536 kg) or less 8 Dump (4,536 kg) or less not Comm 1 Overturn/Rollover 2 10,001.26,000 GVWR/GCWR Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard 2 Fire/Explosion 3 More than 26,0001bs (17,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4 Not Applicable 11 Garbage/Refuse Narrative ❑ 4 Jackknife Collision with Non -Fixed Object 5 Cargo/Equipment Loss or Shift 10 Pedestrian 12 Log 88 Unknown Collision Fixed Object 29 Cable Barrier Emergency 19 Impact Attenuator/Crash 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 9 Other Non -Collision 13 Animal 14 Motor Vehicle in Transport 21 Bridge Pier or Support 32 Tree (standing) 22 Bridge Rail 1 33 Utility Pole/Light Support ❑ 23 Culvert 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support 15 ❑ [40-46 Sequence of Events 40 Failure F3rd only] 16 Work Zone/Maintenance lire, Equipment 24 Curb 35 Traffic Signal Support 1 No 25 Ditch 36 Other Post, Pole, Support equipment (blown or 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 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, buildina. 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 ❑ 5 Turning Right 16 Leaving Traffic Lane 8 Flashing Signal 1 9 Railway Crossing 1 None 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 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 Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve left 11 Overtaking/PassingOvertaking/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 of Motor Vehicle 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign 88 Unknown 9 Exhaust System Safety Chains 1 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 ICLAN 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 7 7 Page of