You are on page 1of 4

FLORIDA TRAFFIC CRASH REPORT

LONG FORM SHORT FORM DRIVER EXCHANGE UPDATE

# OF WITNESSES # OF VEHICLES # OF VIOLATIONS # OF NVPD # OF DRIVERS # OF PASSENGERS # OF NONMOTORIST
0 2 0 0 2 0 0
SUBSEQUENT CRASH EXEMPT FROM PUBLIC RECORDS CRASH DATE TIME OF CRASH DATE OF REPORT REPORTING AGENCY CASE # HSMV CRASH REPORT #

No No 11/26/2018 12:03 PM 11/26/2018 MP20181126-00040404 85853613

CRASH IDENTIFIERS

COUNTY CODE CITY CODE COUNTY OF CRASH PLACE OR CITY OF CRASH WITHIN CITY LIMITS TIME REPORTED TIME DISPATCHED

64 58 COLLIER MARCO ISLAND YES 12:05 PM 12:19 PM

TIME ON SCENE TIME CLEARED SCENE COMPLETED REASON (If Investigation NOT Complete) NOTIFIED BY

12:19 PM 12:50 PM YES LAW ENFORCEMENT

DIAGRAM

11/28/2018 1 OF 4 3:22 PM
NARRATIVE

V-2 was traveling north in the parking lot of 50 Bald Eagle Drive at City Hall in Marco Island, FL. V-1 was backing from a parking space. V-1 traveled into the
path of V-2. V-2 struck the right rear fender of V-1 with the right front fender of V-1. There were no injuries and very minor damage (paint loss) on both
vehicles.

D-1 stated that there was a large vehicle next to V-1 with dark tinted windows and she did not see V-2 while backing. V-1 backed improperly causing the
accident.

ROADWAY INFORMATION

ROAD SYSTEM IDENTIFIER AT STREET ADDRESS # CRASH OCCURRED ON STREET, ROAD, HIGHWAY

PARKING LOT 50 BALD EAGLE DR

AT FEET OR MILES Direction AT/FROM INTERSECTION WITH STREET, ROAD,HIGHWAY AT LATITUDE AND LONGITUDE

STREET LIST USED? Locator Used? OR FROM MILEPOST # TYPE OF SHOULDER TYPE OF INTERSECTION

Yes No CURB NOT AT INTERSECTION

CRASH INFORMATION (CHECK IF PICTURES TAKEN)

LIGHT CONDITION WEATHER CONDITION ROADWAY SURFACE CONDITION SCHOOL BUS RELATED MANNER OF COLLISION/IMPACT

DAYLIGHT 1 - CLEAR DRY 1 - NO REAR TO SIDE

FIRST HARMFUL EVENT FIRST HARMFUL EVENT LOCATION WITHIN INTERCHANGE FIRST HARMFUL EVENT RELATION TO

MOTOR VEHICLE IN TRANSPORT IN PARKING, LANE OR ZONE NO NON-JUNCTION

CONTRIBUTING CIRCUMSTANCES: ROAD CONTRIBUTING CIRCUMSTANCES: ROAD CONTRIBUTING CIRCUMSTANCES: ROAD

NONE

CONTRIBUTING CIRCUMSTANCES: ENVIRONMENT CONTRIBUTING CIRCUMSTANCES: ENVIRONMENT CONTRIBUTING CIRCUMSTANCES: ENVIRONMENT

NONE

WORK ZONE RELATED CRASH IN WORK ZONE TYPE OF WORK ZONE WORKERS IN WORK ZONE LAW ENFORCEMENT IN WORK ZONE

NO

11/28/2018 2 OF 4 3:22 PM
VEHICLE CHECK IF COMMERCIAL
VEHICLE # HIT AND RUN VEHICLE YEAR VEH LICENSE STATE VEHICLE MAKE VEHICLE STYLE VEHICLE COLOR VIN
1 NO 2013 JICH97 FL CADI UTILITY WHITE - WHI 3GYFNGE35DS623825

PERM. REG. REG. EXPIRES VEHICLE MODEL VEHICLE STATUS EXTENT OF DAM. EST. DAM. TOWED DUE TO VEHICLE REMOVED BY ROTATION
VEHICLE IN DAMAGE
NO 07/20/2020 SRX 4 TRANSPORT Minor $ 500 NO DRIVER
INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER

PROGRESSIVE SELECT INSU 925609785
NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY STATE ZIP CODE

LINA UPHAM 1010 MANATEE RD B206 NAPLES FL 34114
TRAILER 1: STATE REG. EXPIRES PERM. REG. VIN YEAR MAKE LENGTH AXLES
LICENSE #

TRAILER 2: STATE REG. EXPIRES PERM. REG. VIN YEAR MAKE LENGTH AXLES
LICENSE #

DIRECTION ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES

WEST 50 BALD EAGLE DR 3 10 2
CMV CONFIGURATION CARGO BODY TYPE
07 07 MOST DAMAGED AREA
AREA OF INITIAL IMPACT
COMM GVWR/GCWR TRAILER TYPE (TRAILER TRAILER TYPE (TRAILER
ONE) TWO) 18 UNDERCARRIAGE 18
NOT APPLICABLE
19 OVERTURN 19
HAZ. MAT. HAZ. MAT. PLA NUMBER CLASS
RELEASE 20 WINDSHIELD 20

MOTOR CARRIER NAME US DOT NUMBER 21 TRAILER 21

MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER

COMM/NON-COMM VEHICLE BODY TYPE VEHICLE DEFECTS (1) VEHICLE DEFECTS (2) EMERGENCY VEHICLE USE UNIT # SPECIAL FUNCTION OF MV

SPORT UTILITY VEHIC NONE NO NO SPECIAL FUNCTION
VEHICLE MANEUVER TRAFFICWAY ROADWAY GRADE ROADWAY ALIGNMENT MOST HARMFUL DETAIL
ACTION
1 - TWO-WAY, NOT DIVIDED S - STRAIGHT
BACKING LEVEL MOTOR VEHICLE IN TRANSPORT
TRAFFIC CONTROL FOR THIS VEHICLE FIRST SEQUENCE OF EVENTS SECOND SEQUENCE OF EVENTS THIRD SEQUENCE OF EVENTS FOURTH SEQUENCE OF EVENTS

NO CONTROLS MOTOR VEHICLE IN TRANSPORT

VEHICLE CHECK IF COMMERCIAL
VEHICLE # HIT AND RUN VEHICLE YEAR VEH LICENSE STATE VEHICLE MAKE VEHICLE STYLE VEHICLE COLOR VIN
2 NO 2016 N264BD FL ACUR UTILITY WHITE - WHI 5FRYD3H47GB001205

PERM. REG. REG. EXPIRES VEHICLE MODEL VEHICLE STATUS EXTENT OF DAM. EST. DAM. TOWED DUE TO VEHICLE REMOVED BY ROTATION
VEHICLE IN DAMAGE
NO 05/20/2019 MDX TRANSPORT Minor $ 1000 NO DRIVER
INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER

ALLSTATE FIRE AND CASUA 9811491290927
NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY STATE ZIP CODE

LOIS ANN GUNTER 5 TAHITI RD MARCO ISLAND FL 34145
TRAILER 1: STATE REG. EXPIRES PERM. REG. VIN YEAR MAKE LENGTH AXLES
LICENSE #

TRAILER 2: STATE REG. EXPIRES PERM. REG. VIN YEAR MAKE LENGTH AXLES
LICENSE #

DIRECTION ON STREET, ROAD, HIGHWAY AT EST. SPEED POSTED SPEED TOTAL LANES

NORTH 50 BALD EAGLE DR 5 10 2
CMV CONFIGURATION CARGO BODY TYPE
02 02 MOST DAMAGED AREA
AREA OF INITIAL IMPACT
COMM GVWR/GCWR TRAILER TYPE (TRAILER TRAILER TYPE (TRAILER
ONE) TWO) 18 UNDERCARRIAGE 18
NOT APPLICABLE
19 OVERTURN 19
HAZ. MAT. HAZ. MAT. PLA NUMBER CLASS
RELEASE 20 WINDSHIELD 20

MOTOR CARRIER NAME US DOT NUMBER 21 TRAILER 21

MOTOR CARRIER ADDRESS CITY STATE ZIP CODE PHONE NUMBER

COMM/NON-COMM VEHICLE BODY TYPE VEHICLE DEFECTS (1) VEHICLE DEFECTS (2) EMERGENCY VEHICLE USE UNIT # SPECIAL FUNCTION OF MV

SPORT UTILITY VEHIC NONE NO NO SPECIAL FUNCTION
VEHICLE MANEUVER TRAFFICWAY ROADWAY GRADE ROADWAY ALIGNMENT MOST HARMFUL DETAIL
ACTION
1 - TWO-WAY, NOT DIVIDED S - STRAIGHT
STRAIGHT AHEAD LEVEL MOTOR VEHICLE IN TRANSPORT
TRAFFIC CONTROL FOR THIS VEHICLE FIRST SEQUENCE OF EVENTS SECOND SEQUENCE OF EVENTS THIRD SEQUENCE OF EVENTS FOURTH SEQUENCE OF EVENTS

NO CONTROLS MOTOR VEHICLE IN TRANSPORT

11/28/2018 3 OF 4 3:22 PM
DRIVER

PERSON # VEHICLE # NAME DOB SEX PHONE NUMBER RE-

1 1 LINA UPHAM F (239) 206-0781 NO

ADDRESS CITY STATE ZIP CODE

1010 MANATEE RD B206 NAPLES FL 34114

DRIVER LICENSE NUMBER STATE EXPIRES DL TYPE REQ. END. INJURY SEVERITY EJECTION
NO REQUIRED NOT
U-150-520-82-760-0 FL 7/20/2023 5 - CLASS E/OPERATO ENDORSEMENTS NONE EJECTED

RESTRAINT SYSTEMS AIR BAG DEPLOYED HELMET USE EYE PROTECTION SEAT ROW OTHER
SHOULDER AND LAP BELT
USED NOT APPLICABLE LEFT FRONT NOT APPLICABLE

DRIVERS ACTION AT TIME OF CRASH (FIRST) DRIVERS ACTION AT TIME OF CRASH (SECOND) DRIVER DISTRACTED BY DRIVER VISION OBSTRUCTION

IMPROPER BACKING NOT DISTRACTED VISION NOT OBSCURED

DRIVERS ACTIONS AT TIME OF CRASH (THIRD) DRIVER ACTIONS AT TIME OF CRASH (FOURTH) DRIVERS CONDITION AT TIME OF CRASH

APPARENTLY NORMAL

SUSPECTED ALCOHOL ALCOHOL TEST ALCOHOL TEST BAC SUSPECTED DRUG USE DRUG TESTED DRUG TEST TYPE DRUG TEST

NO NO

POSITIVE DRUG TEST RESULTS TRANSPORT TO MEDICAL FACILITY BY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO

NOT TRANSPORTED

DRIVER

PERSON # VEHICLE # NAME DOB SEX PHONE NUMBER RE-

2 2 LOIS ANN GUNTER F (239) 389-0353 NO

ADDRESS CITY STATE ZIP CODE

5 TAHITI RD MARCO ISLAND FL 34145

DRIVER LICENSE NUMBER STATE EXPIRES DL TYPE REQ. END. INJURY SEVERITY EJECTION
NO REQUIRED NOT
G-536-521-44-808-0 FL 8/28/2019 5 - CLASS E/OPERATO ENDORSEMENTS NONE EJECTED

RESTRAINT SYSTEMS AIR BAG DEPLOYED HELMET USE EYE PROTECTION SEAT ROW OTHER
SHOULDER AND LAP BELT
USED NOT APPLICABLE LEFT FRONT NOT APPLICABLE

DRIVERS ACTION AT TIME OF CRASH (FIRST) DRIVERS ACTION AT TIME OF CRASH (SECOND) DRIVER DISTRACTED BY DRIVER VISION OBSTRUCTION

NO CONTRIBUTING ACTION NOT DISTRACTED VISION NOT OBSCURED

DRIVERS ACTIONS AT TIME OF CRASH (THIRD) DRIVER ACTIONS AT TIME OF CRASH (FOURTH) DRIVERS CONDITION AT TIME OF CRASH

APPARENTLY NORMAL

SUSPECTED ALCOHOL ALCOHOL TEST ALCOHOL TEST BAC SUSPECTED DRUG USE DRUG TESTED DRUG TEST TYPE DRUG TEST

NO NO

POSITIVE DRUG TEST RESULTS TRANSPORT TO MEDICAL FACILITY BY EMS AGENCY NAME OR ID EMS RUN NUMBER MEDICAL FACILITY TRANSPORTED TO

NOT TRANSPORTED

REPORTING OFFICER

ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT.
POLICE DEPARTMENT
111 OFFICER MARK HUFFOR MARCO ISLAND POLICE DEPARTMENT (PD)

11/28/2018 4 OF 4 3:22 PM