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 10/23/2019 4:12 PM 10/23/2019 MIPD 19102300040846 85853814

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 4:12 PM 4:12 PM

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

4:16 PM 5:20 PM YES LAW ENFORCEMENT

DIAGRAM

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NARRATIVE

Vehicle 2 was heading east on Collier blvd N, over the Tigertail bridge. Vehicle 1 was pulling out of 625 Collier blvd N and turned left in a right turn only area
because of the divided median. Collier Blvd is a 4 lane divided roadway. When the driver of vehicle 2 saw the oncoming car he came to a complete stop and
vehicle 1 crashed head on into vehicle 2. Driver of vehicle 1 at fault for driving against traffic and violation of traffic control device (right turn only sign).

ROADWAY INFORMATION

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

LOCAL 625 COLLIER BLVD N

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 WET 1 - NO FRONT TO FRONT

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

MOTOR VEHICLE IN TRANSPORT ON ROADWAY 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

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 VEHICLE CHECK IF COMMERCIAL
VEHICLE # HIT AND RUN VEHICLE YEAR VEH LICENSE STATE VEHICLE MAKE VEHICLE STYLE VEHICLE COLOR VIN
1 NO 2016 WQM MO TOYOT SUV WHITE - WHI 5TDDKRFHXGS228222

PERM. REG. REG. EXPIRES VEHICLE MODEL VEHICLE STATUS EXTENT OF DAM. EST. DAM. TOWED DUE TO VEHICLE REMOVED BY ROTATION
VEHICLE IN DAMAGE
NO 07/30/2020 HIGHLANDER TRANSPORT Disabling $ 8000 YES TOW SAFE ROTATIO
INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER

OWNERS INSURANCE COMPANY 51 502-603 00C CO 32700

NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY STATE ZIP CODE

JOHN HARRIS WARREN JR. 2117 LAKEVIEW DR CHILLOCOTHE MO 64601

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 COLLIER BLVD N 20 25 4

CMV CONFIGURATION CARGO BODY TYPE
01 01 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

VEHICLE CHECK IF COMMERCIAL

VEHICLE # HIT AND RUN VEHICLE YEAR VEH LICENSE STATE VEHICLE MAKE VEHICLE STYLE VEHICLE COLOR VIN
2 NO 2014 GDP603 FL FRHT TK BROWN - BRO 4UZAC3DV5ECFN5579

PERM. REG. REG. EXPIRES VEHICLE MODEL VEHICLE STATUS EXTENT OF DAM. EST. DAM. TOWED DUE TO VEHICLE REMOVED BY ROTATION
VEHICLE IN DAMAGE
NO 12/31/2019 UPS TRUCK TRANSPORT Functional $ 4000 NO DRIVER DRIVER
INSURANCE COMPANY (DRIVER) INSURANCE POLICY NUMBER

UNITED PARCEL SERVICE INC AS2-C21-004175-339

NAME OF VEHICLE OWNER (CHECK IF BUSINESS) CURRENT ADDRESS CITY STATE ZIP CODE

UNITED PARCEL SERVICE

971 COMMERCIAL BLVD NAPLES FL 34104
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

EAST COLLIER BLVD N 0 25 4

CMV CONFIGURATION CARGO BODY TYPE
01 01 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

CARGO VAN (10,000 V 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

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DRIVER

PERSON # VEHICLE # NAME DOB SEX PHONE NUMBER RE-

1 1 COLE ALLEN NICHOLS M (660) 247-1417 NO

ADDRESS CITY STATE ZIP CODE

1505 MORNINGSIDE DR CHILLICOTHE MO 64601

DRIVER LICENSE NUMBER STATE EXPIRES DL TYPE REQ. END. INJURY SEVERITY EJECTION
NOT
V006294006 MO 7/5/2022 5 - CLASS E/OPERATO NO NONE EJECTED

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

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

WRONG SIDE OR WRONG WAY 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 MARCO EMS 3335

DRIVER

PERSON # VEHICLE # NAME DOB SEX PHONE NUMBER RE-

2 2 BRIAN THOMAS BRANTLEY M (239) 200-0487 NO

ADDRESS CITY STATE ZIP CODE

11703 EROS RD LEHIGH ACRES FL 33971

DRIVER LICENSE NUMBER STATE EXPIRES DL TYPE REQ. END. INJURY SEVERITY EJECTION
NOT
B-653-078-76-143-0 FL 4/23/2022 5 - CLASS E/OPERATO NO NONE EJECTED

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

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 MARCO EMS 3335

REPORTING OFFICER

ID/BADGE # RANK OFFICER NAME DEPARTMENT TYPE OF DEPT.

POLICE DEPARTMENT
95 OFFICER ROBERT MARVIN MARCO ISLAND POLICE DEPARTMENT (PD)

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