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HomeMy Public PortalAboutPRR 23-2976 Renee Basel From:Katrina Herrington <katrina.lawrence76@gmail.com> Sent:Monday, November 27, 2023 3:20 PM To:Renee Basel Subject:Case#23-1025 You don't often get email from katrina.lawrence76@gmail.com. Learn why this is important \[NOTICE: This message originated outside of the Town of Gulfstream -- DO NOT CLICK on links or open attachments unless you are sure the content is safe.\] Hello my name is Katrina Herrington and I wanted to see how I can get a copy of the police report. Thank you 1 TOWN OF GULF STREAM PALM BEACH COUNTY, FLORIDA Delivered via e-mail November 30, 2023 Katrina Herrington [mail to: katrina.lawrence76(a,gmail.com] Re: GS #2976 (Request for Crash Report) I wanted to get a copy of the police report 23-1025. Dear Katrina Herrington [mail to: katrina.lawrence76(agmail.com]: The Town of Gulf Stream has received your public records request dated November 27, 2023. You should be able to view your original request and response at the following link, as of January 27, 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 23-2976 Oaserfiche.com) The police crash report you requested is attached to this e-mail. We consider this request closed. Sincerely, Town Clerk Custodian of Records TOVW OF GULF STREAM POLICE DEPARTMENT oL FLA. Requester's information: Katrina Herrington Name of Requester Pursuant to 316.066(2)(b), Fla. Stat. 11 /27/2023 Date of Request 411 NW 1 st Street 1561) qW-99772 Street Address Telephone Number Boynton Beach FL 33435 city State Tip Crash information: 23-1025 Reference # (Case/File Name) Fax Number katrina.1awrence76 @ gmail.con Email Address 11 /19/2023 231025 23-1025 Date of Crash Crash Report # (if known) Law Enforcement Agency Case # (FHP or other, if known) Al A Palm Bee h Location of Crash County (where crash occurred) Parties Involved 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): ✓❑ I 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 i any third party for purposes of such solicitation. Sig Lure of Reques " r uCM\/ Firm aAnin rRPv 03/2023) Page 1 of 2 STATE OF _ COUNTY OF Sworn to (or affirmed) and subscribed before me by means of ❑ physical presence or ❑ online notarization this day of 20___, by Katrina Herrington —,who is ❑ personally known or ❑ produced identification. Type of identification produced: (NOTARY SEAL) Signature of Notary (Print, Type or Stamp Commissioned Name of Notary Public) 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. :SECTION 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. 4 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 — 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. 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. EJ 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 I understand 1 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. 1eh A Sigriature of Requ6iter HSMV Form 94010 (Rev. 03/2023) Page 2 of 2 FLORIDA TRAFFIC CRASH REPORT LONG FORM ❑� SHORTFORM ❑ UPDATE ❑ (Shaded Areas) MAIL TO: DEPARTMENT OF HIGHWAY SAFETY & MOTOR VEHICLES TRAFFIC CRASH RECORDS, NEIL KIRKMAN BUILDING TALLAHASSEE, FL 32399-0537 WAS DOT PROPERTY INVOLVED IN THIS CRASH? TOTAL # OF VEHICLE SECTION(S) 2 TOTAL # OF PERSON SECTION(S) 3 TOTAL # OF NARRATIVE SECTION(S) 1 1 11/19/2023 1 10:40 AM 111119/2023 1231025 187073153 CRASH IDENTIFIERS COUNTY CODE ITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH CHECK IF WITHIN IME REPORTED IME DISPATCHED CITY LIMITS OG 44 PALM BEACH GULF STREAM 10:45 AM 10:47 AM TIME ON SCENE [ME CLEARED SCENE 111:13 FHECK IF OMPLETED ❑V REASON (If Investigation NOT Complete) Notified By: 1 Motorist 10:52 AM AM 2 Law Enforcement ROADWAY INFORMATION CHOOSE ONLY 1 OF 4 OPTIONS) CRASH OCCURRED ON STREET, ROAD, HIGHWAY �AT STREET ADDRESS # AT LATITUDE AND LONGITUDE In STATE ROAD A7A ALSO KNOWN AS NORTH OCEAN BLVD 26.491683-80.054083 AT FEET MILES N © AT/FROM I TERSECTION WITH STREET, ROAD,HIGHWAY I �OR FROM MILEPOST# ❑S ❑E ❑W DR Road System Identifier 7 Forest Road Type of Shoulder Type of Intersection 5 Traffic Circle 8 Private Roadway 1 Interstate 4 County 9 Parking Lot 2 U.S. 5 Local Other, Explain in 1 Paved 2 Unpaved 1 Not at Intersection 6 Roundabout 2 Four -Way Intersection 7 Five -Point, or More y 1 3 T-Intersection 77 Other, Explain in Narrative 3 State 6 Turnpike/Toll N Narrative 3 Curb 4 Y-Intersection rwan mrurtmfa i iuN tunr %,rx it rw i umro i Amr j Light Condition Weather Condition Roadway Surface Condition School Bus Related Manner of Collision/Impact ❑ 1 Daylight 5 Dark -Not Lighted 1 2 Dusk 6 Dark -Unknown 1 4 Fog, Smog, Smoke 5 Freezing Rain 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 Lighting 4 Dark -Lighted 77 Other, Explain in 6 Blowing Sand, Soil 8 Water Directly Involved 6 Rear to Side Narrative 1 Clear Dirt (standing/moving) 3 Yes, School Bus 1 Front to 7 Rear to Rear Rear 88 Unknown 2 Cloudy y Severe Crosswinds 1 Dry 77 Other, Explain in Indirectly Involved 2 Front to 77 Other, Explain in Narrative Front 3 Rain 77 Other, Explain in 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 1 Overturn/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 18 4 Jackknife 5 Cargo/Equipment engine) 21 Bridge Pier or Support 33 Utility Pole/Light Support 13 Animal 22 Bridge Rail 34 Traffic Sign Support 3 Shoulder 1 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 1 2 Yes 8 Ran into 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 9 Worn, Travel -Polished Surface Contributing Circumstances: Environment Junction 18 5 Railway Grade Crossing 10 Road Surface Condition (wet. 1 icy, snow, slush, etc.) 14 Entrance/Exit Ramp 11 Obstruction in Roadway 1 Non -Junction 15 Crossover- Related 12 Debris 1 None 16 Shared -Use of Path or Trail 13 Traffic Control Device 1 None 5 Animal(s) in Roadway 2 Intersection 17 Acceleration/Deceleration 4 Work Zone construction/ e, Missing or Obscured Inoperati v 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 Related 77 Other, Explain in Narrative 7 Rut, Holes, Bumps 88 Unknown 4 Glare 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 lCrossover ❑ 3 Work on Shoulder in Median 4 Intermittent or Moving Work 1 No ❑ 2 Yes 88 Unknown 4 Activity Area y 77 Other, Explain in Narrative 88 Unknown 5 Termination Area 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 # 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 _ VEHICLE # 1 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 231025 87073153 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent VIN 2 Parked Motor Vehicle 1 3 Working Vehicle QKBR63 FL 06/06/2024 Registration ❑ 19UDE2F38JA000986 Hit and Run 1 No 1 YEAR MAKE I MODEL STYLE 1 COLOR DAMAGE: 1 Disabling 4 Minor T. AMOUNT 2 Yes 018 ACUR ILX I 1 DOOR SEDAN BLACK - BLK 2 Functional 88 Unknown 2 V000.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER Towed due to Damage.1 VEHICLE REMOVED BY 1. Rotation 2. Owner Request 14. 3 GEICO CASUALTY COMPANY 6133163276 1 No 2 Yes DRIVER 3. Driver Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) ❑ CURRENT ADDRESS CITY & STATE ZIP KATRINA LEEANNA HERRINGTON 411 NW 1ST ST BOYNTON BEACH FL 133435 Trailer LICENSE NUMBER STATE REGISTRATION EXPIRES Check if Permanent IN 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 ❑ ❑ ❑ R ❑ ❑ NORTH OCEAN BLVD 15 35 AZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area 2 Yes ❑ 2 Yes ❑ OS 05 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 Unknown 88 Unknown 19 Overturn 19 1 15 16 17 8 1 15 16 17 8 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER 14 9 21 Trailer 21 14 9 13 121110 13 121110 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 ❑ 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 17 Cargo Van (1s) Ibs (4,536 kg) or less) 2 Two -Way, Not Divided, with a 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify 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 occupants, including driver 3 Single -Unit Truck (3 or more axles) P 9 ) 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) 4,536 k 8 Bus than 10,000 Ibs 9)) ( , Explain in Narrative One -Way Traffcway P 6 Truck Tractor/Semi-Trailer 77 Other 5 On 11 Motorcycle 21 Farm Labor Vehicle 7 Truck Tractor/DoublTruck e 88 Unknown 88 Unknown 12 Moped 77 Other, Explain in Narrative Trailer Type 13 All Terrain Vehicle (ATV) 88 Unknown 1 Single Semi Trailer 8 Pole Trailer 2 Tandem Semi Trailer 9 Towed Vehicle Cargo Body Type Comm/Non-Commercial 13 TRAILER11 TRAILER 2 dal 3 Tank Trailer 10 Auto Transport 1 Interstate Carrier Container Ch 4 Hopper 14 Vehicle Towing ❑ ❑ 4 Saddle Mount/Trailer 77 Other, Explain in ❑ 3 Van/Enclosed Box Container Chassis 5 Boat Trailer Narrative 2 Intrastate Carrier ❑ 5Pote-Trailer Another Vehicle 6 Utility Trailer 88 Unknown7 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 'No 4 Not in Commerce/Other Truck House Trailer Cargo 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 Overturn/Rollover GVWR/GCWR 4 2 10,001-26,000 Ibs (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 18 5 Cargo/Equipment Loss or Shift 10 Pedestrian 29 Cable Barrier Emergency Cushion 6 Fell/Jumped From Motor Vehicle 11 Pedalcycle 20 BridgImpae 30 Concrete Traffic Barrier Vehicle Use Structure 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 21 Bridge Pier or Support 13 Animal 32 Tree (standing) 9 Other Non -Collision 14 Motor Vehicle in Transport 22 Bridge Rail 1 33 Utility Pole/Light Support ❑ 23 Culvert 1st 2nd 15 Parked Motor Vehicle 34 Traffic Sign Support [40-46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1No 18 15 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 41 Separation of Units 88 Unknown 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 buildinq, tunnel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 46 Downhill Runaway 3 Turning Left 14 Slowing This Vehicle 1 Straight Ahead 13 Stopped in Traffic ❑ ❑ 1 Level 2 Hillcrest ❑ 4 Backing 15 Negotiating a Curve 8 Flashing Signal 1 None 5 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing Roadway Alignment 1 No Controls 2 Brakes 13 Wheels 1 3 Uphill 4 Downhill ❑ 1 Straight 1 6 Changing Lanes 17 Entering Traffic Lane Device 4 School Zone Sign/ 3 Tires 14 Windows/ 8 Parked 77 Other, Explain in Narrative 10 Person (including Device 4 Lights (head, Windshield 5 Sag (bottom) 2 Curve Right 10 Making U-Turn 88 Unknown Flagman, Officer, 5 Traffic Control signal, tail) 15 Mirrors 3 Curve Lek 11 Overtaking/PassingGuard, etc.) Signal 6 Steering 16 Truck Coupling 77 Other, Explain in Special Function 1 No Special Function 9 Ambulance 14 Intercity Bus 6 Stop Sign 7 Wipers Trailer Hitch/ Narrative 2 Farm Vehicle 1 of Motor Vehicle 10 Fire Truck 15 Charter/Tour 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 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 8 Page of _ PERSON # 1 Reporting Agency Case Number HSMV Crash Report Number 231025 87073153 1 Driver VEHICLE # NAME PHONE NUMBER Check if ❑ 2 Non -Motorist 1 ❑ 1 Recommend 3 Passenger KATRINA LEEANNA HERRINGTON (561) 306.9772 Driver Re -exam CURRENT ADDRESS (Number and Street) CITY & STATE ZIP CODE 411 NW 1ST ST BOYNTON BEACH FL 33435 DATE OF BIRTH SEX: 1 Male ❑ DRIVERS LICENSE NUMBER TATE EXPIRES INJURY SEVERITY (INJ)4 Incapacitating ❑ 2 Female 2 Possible 5 Fatal (within 30 days) 06/06/1976 88 Unknown H652512767060 FL 06/06/2027 3 Non -Incapacitating 6 Non -Traffic Fatality RIVER DL Type Required Endorsements 1st 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 4 D/Chauffeur 2 Operated MV in Careless or 27 Disregarded other Traffic Crash 5 3 1 Yes 77 1 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 4 Other Inside the Vehicle Steering 6 Seizure, Epilepsy, Blackout (explain in narrative) 10 Followed too Closely 7 Physically Impaired 1 Not Distracted 2nd 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 hone, etc. 1 9 Under the Influence of ( P in narrative) 13 Ran Stop Sign ❑ Object, Non -Motorist in 3 Other Electronic Device 6 Textin 15 Improper Passin 1 Medications/Drugs/Alcohol 9g 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 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 3 ❑ 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 ❑ (RS) DRIVER OR PASSENGER ❑ 1 DOT -Compliant ❑ 1 Yes SEAT ROW OTHER Motorcycle Helmet 2 No [OCATION: Motor Vehicle Seating Position: 2 Other Helmet 3 Not Applicable 1 Not Applicable (non -motorist) OC) 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 2 Middle 2 Second Car9 O Area Ejection (EJECT) 6 Restraint Used - Type Unknown 3 Right 3 Other Enclosed (knee, air belt, etc.) 77 Other 3 Third 4 Unenclosed Cargo Area 1 Not Ejected 1 Not Applicable 7 Child Restraint System - Forward Facing 2 6 Deployed - (explain in 4 Fourth 2 Ejected, Totally 2 Not De to ed 8 Child Restraint System -Rear Facing 5 Trailing Unit 1 P Y Combination narrative 3 Ejected, 77 Other Row 1 3 Deployed -Front 7 Deployed -Curtain 9 Booster Seat 88 Unknown 88 Unknown 6 Riding on Motor Vehicle Exterior (non- Partially 4 Deployed -Side 10 Child Restraint Type Unknown Deployment trailing unit) 4 Not Applicable U 77 Other, Explain in Narrative Unknown 88 Unknown 88 Unknown NON-M TORI T Nun -Motorist Description ❑ 1 Pedestrian Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash ❑ 1 Intersection - Marked Crosswalk ❑ 5 Walking/Cycling on Sidewalk 9 Median/Crossing Island 2 Other Pedestrian (wheelchair, person in a 2 Intersection Unmarked Crosswalk 6 In Roadway —Other (working, building, skater, pedestrian conveyance, etc. - 10 Driveway Access Y 3 Bicyclist 3 Intersection - Other4 Midblock -Marked Crosswalk 11 Shared -Use Path or Trail 1 CrossingRoadway Playing, etc.) y 4 Other Cyclist 4 Midblock - Marked Crosswalk 12 Non 7 Adjacent to Raodway (e.g., Area Waiting to Cross Roadway 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location 77 Other, Ex lain in Narrative shoulder, median) r, Explain P Walking/Cycling Along 6 Bicycle Lane 8 Going to or from School (K-12) y (parked, etc.) 88 Unknown Roadway with Traffic (in or 7 shoulder/Roadside (iWorking in 6 Occupant of a Non -Motor Vehicle once)Trafficway djacent to travel lane) (incident response) Transportation Device Non -Motorist Action SICIrcurnstances 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 sr 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 Not Applicable Protective Pads Used ❑ e ❑ Signals, or Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge a Vehicle 11 Improper Passing Roadway Improperly 77 Other, Explain elbows, knees, shins, etc.) in Narrative 5In (standing, lying, working, playing) 8lnattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking Reflective Clothing (jacket, 88 Unknown 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 gqC USPECTED RUG TESTED: RUG TEST TYPE: RUG TEST RESULT: USE: No Test Not 2 Test do ❑ Blood 2 Breath 17 ❑ EST RESULT: 1 ❑ RUG Nes USE: � 1 Test edTest Not n ❑ lood 1 Bother, rine❑ I Positive ative ❑ 21 Y 2 Yes s Given 3 Test Given Other, Explain COMPLE`�TED Test Giveno 3 Pending 88 Unknown 88 Unknown, if Tested n Narrative 8 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 PASSENGERS PERSON # EHICLE # JAME ATE OF BIRTH INJ SEX ILOCS IR O EJECT I J HU 1EP I ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE SOURCE OF TRANSPORT TO MEDICAL FACILITY [:][MS 1-Tnn W,p 2EMS 3 Lew E,Mc nt 77 OMer, Epl., in Na—. unxn— AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO PERSON # EHICLE # AME ATE OF BIRTH I INJ SEX ILOC:S IR O EJECT J HU EP I ABD I IRS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE OURCE OF TRANSPORT TO MEDICAL FACILITY 1 Not Trenepo 2 EMS 3 Lew Enbrcem 77 0— Explain In Neva Nunknovm ❑ EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO HSMV 90010 S 3 8 Page of _ PERSON # 2 1 Driver VEHICLE# NAME 2 Non -Motorist El I 3 Passenger HERBY CURRENT ADDRESS (Number and Street) 207 SW 14TH AVE DATE OF BIRTH SEX: DRI' 1 Male 1 ❑ 2 Female 188 09/30/1984 Unknown ❑ DL Type 1A2B 3 Required ❑ Endorsements 4 D/Chauffeur 5 E/Operator 6 E/Oper-Rest 1 Yes 2 No 3 No Req. Endorsement 7 None Driver Distracted By 4 Other Inside the Vehicle ❑ (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 Taxiing (navigation device, DVD player) 7 Inattentive 88 Unknown Reporting Agency Case Number HSMV Crash Report Number 231025 87073153 PHONE NUMBER Check if El ST FORT 5617225686 Driver Re -exam CITY & STATE ZIP CODE DELRAY BEACH FL 33444 IBER TATE EXPIRES INJURY SEVERITY(INJ)4 Incapacitating 1 None 2 Possible 5 Fatal (within 30 days) 1 3 Non -Incapacitating 6 Non -Traffic Fatality 1st 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 Slop 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 or Agreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action ❑ , vision ry k7oscurea 5 Load on Vehicle 9 Smoke 2 Inclement Weather 6 Building/Fixed Object 10 Glare 3 Parked/Slopped 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 RO OTHER Motorcycle Helmet Motor Vehicle Seating Position: LOCATION: ❑ ❑ ❑ 2Other Helmet Seat Row Other LOC) 3 No Helmet 1 Left 1 Not Applicable 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 Medications/Drug s/Alcoho I 77 Other, Explain in Narrative 88 Unknown Eye Protection (EP) ❑ Restraint Systems ❑ 1 Yes (RS) 2 NO 3 Not Applicable 1 Not Applicable (non -motorist) 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 4 Shoulder Belt Only Used 1 Front 2 Middle9 2 Second 2 Sleeper Section of Truck Cab Air Bag Deployed Y 5 Deployed -Other 5 Lap Belt Only Used Ejection (EJECT) 3 Right 3 Other Enclosed Cargo Area 3 Third g (knee, air belt, etc.) 6 Restraint Used - Type Unknown 77 Other 4 Unenclosed Cargo Area in 1 Not Ejected 2 Ejected, Totally 1 NotApplicable y 6 Deployed- 7 Child Restraint System -Forward Facing explain 4 Fourth 5 Trailing Unit 1 Y 2 Not Deployed Combination robin 8 Child Restraint System -Rear Facing narrative 77 Other Row 88 Unknown 88 Unknown 6 Riding on Motor Vehicle Exterior (non- 3 Ejected, 1 Partially 3 Deployed -Front 7 Deployed -Curtain 4 Deployed -Side 88 Deployment 9 Booster Seat 10 Child Restraint Type Unknown trailing Unit) 4 NotApplicable Unknown 77 Other, Explain in Narrative 88 Unknown 88 Unknown N N-M T RI T Noon -Motorist Description 1 Pedestrian Other Pedestrian in a Non -Motorist Location At Time of Crash Action Prior to Crash 8 Sidewalk 1 Intersection - Marked Crosswalk 9 Median/Crossing Island ❑ 5 Walking/Cycling on Sidewalk 9 6 wheel con person 1 building, skater, pedestrian conveyance, etc. �2 2 Intersection -Unmarked Crosswalk 10 Driveway Access 6 In Roadway —Other (working, 5 Y Playing, etc.) 3 Intersection - Olher4 Midblock -Marked Crosswalk ❑ 3 Bicyclist 11 Shared -Use Path or Trail 1 Grossing Roadway 9 Y 7 Adjacent to Raodway 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non-Trafficwa Area (e.g., 5 Travel Lane - Other Location y Waiting to Cross Roadway shoulder, median) 5 Occupant of Motor Vehicle Not in Transport Along 77 Other, Explain in Narrative Walking/Cyclingwawith 6 Bicycle Lane 88 Unknown Roadway with Traffic in or 8 Going to or from School (K-12) Traffic y ( (parked, etc.) 6 Occupant of a Non -Motor Vehicle 7 shoulder/Roadside (iWorking in Trafficway adjacent to travel lane) (incident response) Transportation Device on- o or s cons rcums antes 4 Walking/Cycling Along 10 None 7 Unknown Type of Non -Motorist 1No Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative 7st 1 2 Dart/Dash ❑ 3 Failure to Yield Right -of -Way 4 Failure to Obey Traffic Signs Signals, Officer 7 or adjacent to travel lane) 88 Unknown Entering/Exiting Parked/Standing 10 Improper Tum/Merge I None Safety Equipment 5 Lighting Helmet 6 No Not 3 Protective Pads Used 77 Other, Explain or 2nd 5 In Roadway Impropedy (standing, Vehicle ❑ 11 Improper Passing elbows, knees, shins, etc.) in Narrative lying, working, playing) 8Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking t Reflective Clothing (jacket, 88 Unknown ❑ 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 At COWnl InPI Ir;/FMS SUSPECTED LCOHOL TESTED: ALCOHOL TEST TYPE: ALCOHOL BAD USPECTED DRUG TESTED: RUG TEST TYPE: RUG TEST RESULT: ALCOHOL USE: Test Not 2 Test Refused ❑ Breath lood 1 BOther,2Explain ❑ TEST RESULT 1 ❑ ❑ DYes USE: ❑ I Test Not lood d n ❑ UOther, ❑ 2 Yes 3 Test Given COMPLETED 3 Test Gi 1 3 Pending 88 Unknown 88 Unknown, if Tested in Narrative 88 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 MEDICAL 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 INJ SEX LOC: S R O 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 Tenep 2EMS 3 Lew Enbcem 77 0—, Exp-,n Ne . N Unknonn ❑ ERSON # EHICLE # AME ATE OF BIRTH INJ SEX LOC: S R O EJECT 1HU J 1EP JABD L CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE OURCE OF TRANSPORT TO MEDICAL FACILITY Ek4S AGENCY NAME OR ID EMS RUN NUMBER k4EDICAL FACILITY TRANSPORTED TO 1 Not TeneporteE 2 EMS 3 Lew E,brc nt 77 0—, E.",n in NeneOve BB Unknwrt, ❑ HSMV 90010 S 4 8 Page of _ Reporting Agency Case Number HSMV Crash Report Number NARRATIVE 231025 87073153 VEHICLE 1 WAS EXITING DRIVEWAY OF RESIDENCE AT 2985 NORTH OCEAN BLVD HEADING WEST. VEHICLE 2 WAS PARKED ALONG THE SHOULDER SLIGHTLY NORTH OF THE DRIVEWAY. V1 EXECUTED A RIGHT TURN TO ENTER ROADWAY AND DRIVE NORTHBOUND. V2, A LARGE BOX TRUCK, IS EQUIPPED WITH A LIFTGATE ON THE REAR OF THE VEHICLE. THE LIFTGATE WAS IN AN OPEN POSITION. AS V1 MADE RIGHT TURN, THE RIGHT REAR DOOR MADE CONTACT WITH THE OPEN LIFTGATE OF V2 CAUSING DAMAGE. V2 WAS NOT DAMAGED. END. ADDITIONAL PASSENGERS ERSON # I EHICLE# JAME DATE OF BIRTH I INJ SEX ILOC S IR 0 EJECT HU EP I 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 Not Transpo— 2 EMS 3 Law Enk`mment 72 Omer_ Expl— in Nartabva 08 Unknown ❑ ERSON # I EHICLE # �AME DATE OF BIRTH I INJ SEX ILOC:S IR O EJECT J HU EP ABD RS CURRENT ADDRESS (Number and Street) CITY STATE ZIP CODE OURCE OF TRANSPORT TO MEDICAL FACILITY MS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO of —pp— 2 EMS 3 Law Enlace —1] Omer. E.plain in arr-N Unknown E: •• •NAL 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 NAME DEPARTMENT YPE OF DEPT. [TFICER POLICE DEPARTMENT 750 OFFICER ODD E SUTTON GULF STREAM POLICE DEPARTM PD) HSMV 90010 S 5 8 Page of _ HSMV 90010 S 6 8 Page of _ VEHICLE # 2 Check if Commercial Reporting Agency Case Number HSMV Crash Report Number ❑ 1 231025 87073153 1 Vehicle in Transport VEHICLE LICENSE NUMBER STATE REGISTRATION EXPIRES VIN Check 'rf Permanent 112/31/2024 2 Parked Motor Vehicle 2 3 Working Vehicle 3749AU FL Registration ❑ 11HTEUMML4PS061472 Hit and Run 1 No 1 YEAR MAKE MODEL STYLE COLOR DAMAGE: 1 Disabling 4 Minor 3 [EST. AMOUNT 2 Yes 023 INTL MV607 RUCK HITE - WHI 2 Functional 88 Unknown 0.00 88 Unknown 3 None INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER 11 Towed due to Damage: 1 VEHICLE REMOVED BY 1. Rotation Owner Request 3 EAN HOLDINGS SELF INSURED 4620Driver No 2 Yes CHRISTAME JEAN 3. 4. Other, Explain in Narrative NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY 8 STATE ZIP ATLAS PARTY RENTALS 1926 HIGH RIDGE RD BOYNTON BEACH FL 33428 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 TRAVELING ❑ ❑ ❑ ❑ R ❑ 985 NORTH OCEAN BLVD 10 1POSTED77777LANES 35 AZ. MAT. RELEASED 1 No HAZ. MAT. PLACARD 1 No NUMBER CLASS Area of Initial Impact Most Damaged Area Q9 09 2 Yes ❑ 2 Yes ❑ 188 2 3 4 5 6 7 18 Undercarriage 18 2 3 4 5 6 7 88 Unknown Unknown 19 Overturn 19 1 15 16 17 6 1 15 16 17 8 20 Windshield 20 MOTOR CARRIER NAME US DOT NUMBER AN HOLDINGS LLC 14 13 12 11 0 9 21 Trailer 21 14 13 12 11 10 9 MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER 14002 E 21ST ST STE 1500 TULSA JOK 174134 (866) 300-4407 Vehicle Body Type 15 Low Speed Vehicle Trafficway Commercial Motor Vehicle Configuration ❑ 16 (Sport) Utility Vehicle 20 1 Two -Way, Not Divided 1 Vehicle 10,000 Ibs or less Placarded 8 Tractor/Triple 1 for Hazardous Materials 9 Truck more than 10,000 Ibs (4,536 17 Cargo Van (10,000 Ibs (4,536 kg) or less) 2 Two -Way, Not Divided, with a ❑ 2 Single -Unit Truck (2-axle and GVWR kg), Cannot Classify Continuous Left Turn Lane 2 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 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) 3 Pickup (4,536 kg) or less) 4 Two -Way, Divided, Positive 4 Truck Pulling Trailer(s) 11 Bus (seats for more than 15 Median Barrier 5 Truck Tractor (bobtail) occupants, including driver 7 Motor Home 20 Medium/Heavy Trucks (more P 9 ) 4,536 k 8 Bus than 10,000 Ibs 9)) ( 6 Truck Tractor/Semi-Trailer 77 Other7 Truck Tractor/Double Truck , Explain in Narrative 5 One -Way Trafficway p 11 Motorcycle 21 Farm Labor Vehicle gg Unknown 88 Unknown 12 Moped 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 131ntennodal 3 Tank Trailer 10 Auto Transport 1 Interstate Carrier 3 Van/Enclosed Box Container Chassis 5 Boat Trailer Narrative 4 Hopper 14 Vehicle Towing ❑ ❑ 4 Saddle Mount/Trailer 77 Other, Explain in 11 4 2Intrastate Carrier ❑ 5 Pole -Trailer Another Vehicle 6 Utility Trailer 88 Unknown 3 Not in Commerce/Government 6 Cargo Tank 15 Not Applicable 7 House Trailer 1 No Cargo 4 Not in Commerce/Other Truck 7 Flatbed (vehicle 10,000 Ibs Most Harmful Event Non -Collision 1 10,000 Ibs (4,536 kg) or less 2 Bus 8 Dump (4,536 kg) or less not 1 Overtum/Rollover ❑ 2 10,001-26,000 Ibs (4,536-11,793kg) 9 Concrete Mixer displaying HM placard CGVIZGCWR2 2 Fire/Explosion 3 More than 26,000 Ibs (11,793kg) 10 Auto Transport 77 Other, Explain in 3 Immersion 4Not Applicable 11 Garbage/Refuse Narrative 4 Jackknife 15 5 Cargo/Equipment Loss or Shift Collision with Non -Fixed Object Collision Fixed Object 12 Log 88 Unknown 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 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 22 Bridge Rail 1 14 Motor Vehicle in Transport 33 Utility Pole/Light Support 23 Culvert ❑ 1st 2nd 15 Packed Motor Vehicle 34 Traffic Sign Support [40.46 Sequence of Events only] 16 Work Zone/Maintenance 24 Curb 35 Traffic Signal Support 1 No 15 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 3rd Anything Set in Motion by Motor 27 Guardrail Face 38 Mailbox 407 42 Ran Off Roadway, Right ❑ ❑ 43 Ran Off Roadway, Left Vehicle 28 Guardrail End 39 Other Fixed Object (wall, 18 Other Non -Fixed Object buildinq nel etc. 44 Cross Median Vehicle Maneuver Action Traffic Control Device For Vehicle Defects 45 Cross Centerline Roadway Grade 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 2 Hilicrest Roadway Alignment 1 3 Uphill 1 None 8 5 Turning Right 16 Leaving Traffic Lane 9 Railway Crossing ❑ 1 No Controls 2 Brakes 13 Wheels 6 Changing Lanes 17 Entering Traffic Lane 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 , Officer, 5 TFlagmanOraffic Control signal, tail) 15 Mirrors 3 Curve Left 11 Overtakin /Passin 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/ 2 Farm Vehicle 1 of Motor Vehicle Na native 9 Exhaust System Safety Chains 10 Fire Truck 15 Charter/Tour Bus 7 Yield Sign 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 I A I 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 8 Page of _ _ PERSON # 3 Reporting Agency Case Number HSMV Crash Report Number 231025 87073153 1 Driver IVEHICLE# NAME PHONE NUMBER Check if 2 Non -Motorist Recommend WISNEL CHRISTAME JEAN 15615421792 Driver Re -exam❑ 3 Passenoer CITY & 629 GARDEN CRESS TRL ROYAL PALM BEACH FL 133411 DATE OF BIRTH SEX: DRIVERS LICENSE NUMBER TATE EXPIRES INJURY SEVERITY (INJ) 1 Male 1 None 4 Incapacitating 2 Female 1 2 Possible 5 Fatal (within 30 days) 09/23/1963 88 Unknown 3 Non -Incapacitating 6 Non -Traffic Fatality DL Type Required Endorsements ❑ 1A 2B 3❑ 4 D/Chauffeur 1 Yes 5 E/Operator 2 No 6 E/Oper-Rest 3 No Req. Endorsement 7 None Driver Distracted By 4 Other Inside the Vehicle ❑ (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, DVD player) 7Inattentive 88 Unknown 1st 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 12 Drove too Fast for Conditions to Wind, Slippery Surface, MV, 13 Ran Slop 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 or Agreessive Manner 25 Failed to Keep in Proper Lane 77 Other Contributing Action ❑ T vision "'vo""' 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/CropsBushes 8 Fog in Narrative Helmet Use (HU) DRIVER OR PASSENGER ❑ 1 DOT -Compliant SEAT _767-7MOT-1 Motorcycle Helmet Motor Vehicle Seating Position: LOCATION: 2 Other Helmet Seat Row Other LOC) 3 No Helmet 1 Left 1NotApplicable 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 DRIVER OR PASSENGER Eye Protection (EP) ❑ Restraint Systems ❑ 1 Yes (RS) 2 No 3 Not Applicable 1 1 Not Applicable (non -motorist) 2 Midde 1 Front 2 Second 2 Sleeper Section of Truck Cab Air Bag Deployed 5 Deployed -Other 3 Right 77 Other 3 Third 3 Other Enclosed Cargo Area g 4 Unenclosed Cargo Area Ejection (EJECT) 1 Not Ejected (knee, air belt, etc.) ❑ 1 Not Applicable 6 in narrative) 4 Fourth 77 Other Row 5 Trailing Unit g ❑ 2 Ejected, Totally 3 Ejected,Deployed-Front 1 2 Not Deployed Combination 88 Unknown gg Unknown 6 Riding on Motor Vehicle Exterior (non- Partially eCombination 3 Deployed -Front 7 Deployed -Curtain 4 Deployed -Side Deployment trailing unit) 4 Not Applicable U Unknown 88 Unknown 88 Unknown 2 None Used - Motor Vehicle Occupant 3 Shoulder and Lap Belt Used 4 Shoulder Belt Only Used 5 Lap Bell Only Used 6 Restraint Used - Type Unknown 7 Child Restraint System - Forward Facing 8 Child Restraint System - Rear Facing 9 Booster Seat 10 Child Restraint Type Unknown 77 Other, Explain in Narrative Nocn-motorist uescripuon 1 Pedestrian Non -Motorist Location At Time of Crash 8 Sidewalk Action Prior to Crash 1 building, skater, pedestrian conveyance, etc. ❑2 Other Pedestrian (wheelchari, person in a t Intersection - Marked Crosswalk 2 Intersection -Unmarked Crosswalk 10 ❑ 1 Median/Crossing Island 10 Driveway Access Y 7 ❑ 5 Walking/Cycling on Sidewalk 6 In Roadway —Other (working, 3 Bicyclist 3 Intersection-Other4 Midblock- Marked Crosswalk 11 Shared -Use Path or Trail 1 Crossing Roadway 9 Y playing, etc.) 4 Other Cyclist 4 Midblock -Marked Crosswalk 12 Non sway Area Waiting to Cross Roadway 7 Adjacent to Raodway (e.g., 5 Occupant of Motor Vehicle Not in Transport 5 Travel Lane -Other Location 6 Bicycle Lane r, Ex 77 Other, Explain in Narrative Along shoulder, median) 8 Going to or from School (K•12) (parked, etc.) 6 Occupant of a Non -Motor Vehicle 7 shoulder/Roadside 88 Unknown Roadway with Traffic (in or oadwagw with Traffic adjacent to travel lane) 9 Working in Transportation Device on- o ortst cons ircumstances 4 Walking/Cycling Along e)way (incident response) 10 None 7 Unknown Type of Non -Motorist 1 N 0Improper Action Roadway Against Traffic (in 77 Other, Explain in Narrative �sr 1 ❑ 2 Dart/Dash or adjacent to travel lane) 88 Unknown 3 Failure to Yield Right -of -Way 1 None Safety Equipment 5 Lighting Helmet 4 Failure to Obey Traffic Signs Signals, Officer 7 Entering/Exiting Parked/Standing 10 Improper Tum/Merge 6 Not Applicable Protective Pads Used 77 Other, Explain 2nd or 5 In Roadway Improperly (standing, Vehicle 11 Improper Passing elbows, knees, shins, etc.) in Narrative lying, working, playing) 8 Inattentive (talking, eating, etc) 12 Wrong -Way Riding or Walking Reflective Clothing (jacket, 88 Unknown ❑ 6 Disabled Vehicle Related (working 9 Not Visible (dark clothing, no 77 Other, Explain in Narrative ackpack, etc.) on, pushing, leaving/approaching) lighting, etc.) At rntani rnDlIrarGeee 88 Unknown SUSPECTED LCOHOL TESTED: ALCOHOL TEST TYPE: LCOHOL BAC USPECTED RUG TESTED: RUG TEST TYPE: RUG TEST RESULT: ALCOHOL USE: 1 No 1 ❑ 1 Test Not Given ❑ Test 1 Blood 2 Breath ❑ 3 Urine EST RESULT: PENDING8 1g RUG USE: [88 Test Not Given ❑ Test Blood rineer,❑ 1 Positive ative 2 Yes 3 Test Given 77 trrativeExplain 1111 Yes 3 ❑ Test Given 7 ding Unknown ❑ 88 Unknown 88 Unknown2 , Tested n Na UNKNOWN Unknown UnknoNo wn, Tested pllahn in Narrative 88 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 ERSON # EHICLE # JAME I DATE OF BIRTH I INJ I SEX I LOC: S I R O EJECT HU 1EP 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 i Not T-p- i EMS 3 Lew Enbrcem 77 OMw,Eple in ❑[MS NanaCve W Unknown ERSON # EHICLE # AME DATE OF BIRTH I INJ SEX ILOC:S IR O EJECT 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 ❑EMS i Nol Trenep 12 EMS 3 Law Enbrpe W77 Oft, Expbinb NarraEvp BB Unknown HSMV 90010 S 8 8 Page of _