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FLORIDA TRAFFIC CRASH REPORT

LONG FORM

SHORT FORM

HIGHWAY SAFETY & MOTOR VEHICLES

TRAFFIC CRASH RECORDS
NEIL KIRKMAN BUILDING, TALLAHASSEE, FL 32399-0537

Ix I UPDATE D

(Electronic Version)
Time of Crash

Crash Date

I 11 :04

JUNE 26, 2013

Date of Report

AM

I JUNE

HSMV Crash Report Number

Reporting Agency Case Number

!130600794

26, 2013

I 83950527

rll..n,._,~ -I lll::::ll'Hll ::11

County Code

40

Time on Scene

I FORT PIERCE
I Reason (if Investigation NOT Complete)

ST LUCIE
ITime Cleared Scene Completed

11 :08AM

11 :30AM

Within City Limits

Place or City of Crash

ICity Code !County of Crash

24

YES

Time Reported
I 11:04 AM
Notified By

MOTORIST

IO

Crash Occurred On Street, Road, Highway

S 25TH ST
Direction

80

At Street Address #

At I From Intersection With Street, Road, Highway

I . VIRGINIA AVENUE
Type of Shoulder

Road System Identifier

11:05 AM

YES

At Feet

ITime Dispatched

Type of Intersection
I 1 NOT AT INTERSECTION

I 3 CURB

5 LOCAL

At Latitude

And

Longitude

IO

Or From Milepost#

Light Condition

Weather Condition

Roadway Surface Condition

School Bus Related

Manner of Collision

1 DAYLIGHT

1 CLEAR

1 DRY

1 NO

1 FRONT TO REAR

14 COLLISION WITH MOTOR VEH IN

I TRANSPORT
'

2 COLLISION WITH NON-FIXED

OBJECT
Contributing Circumstances: Road

Within Interchange First Harmful Event Relation to Junction

First Harmful Event Location

First Harmful Event

First Harmful Event Type

1 NO

1 ON ROADWAY

1 NON-JUNCTION

Contributing Circumstances: Road

!
'
Contributing Circumstances: Road

Contributing Circumstances: Environment

Contributing Circumstances: Environment

'

1 NONE
Contributing Circumstances: Environment
Work Zone Related ICrash in Work Zone

I Workers in Work Zone I Law Enforcement in Work Zone

I Type of Work Zone

1 NO

''

Vehicle

Motor Vehicle Type

01

1 VEH IN TRANSPORT

Hit and Run

I 1 NO
Style

Year

Veh License Number

FL

Extent of Damage
A

1-2002

IState IReg. Expires

AQMH63
.............

!Permanent Reg. IVIN

AUGUST 26, 2013

jEst. Damage
4t'l:'on

1 NO

1C8GJ253X2B599327

jTowed Due To Damage jVehicle Removed By

...........

Rotation

Insurance Policy Number

Insurance Company (Driver)

! A9012101540
City & State

METROPOLITAN CASUALTY INS. CO.

Name of Vehicle Owner (Business)

Current Address

FRANCES G. CENDEJAS

Zip Code

PORT SAINT LUCIE, FL

874 SW HAMBERLAND AVE

34953

Trailer
One :

License Number

State

Reg. Expires

Permanent Reg.

VIN

Year

Make

Length

Axles

Trailer
Two:

License Number

State

Reg. Expires

Permanent Reg.

VIN

Year

Make

Length

Axles

Vehicle
Traveling

On Street, Road, Highway

Direction
N

At Est. Speed
I 40

S 25TH STREET

CMV Configuration

I Cargo Body Type

Trailer Type (Trailer Two)

Trailer Type (Trailer One)

I
1-H-a-z.-M-at-.-Re~l-ea_s_e_TIH_a_z_.M-at-.-P~la-c-ar_d_...,._N_u_m_b_er--------~-..,IC,,..la_s_s--------1
Motor Carrier Name

US DOT Number

Motor Carrier Address

City & State

Comm/Non-Commercial

Vehicle Body Type

Vehicle Maneuver Action

1 STRAIGHT AHEAD

1 TWO-WAY, NOT DIVIDED

HSMV90010 S

I6

~-

X
d(~"' 16 117 -~
0
/I"
JI.. I 13 112 111 110 9

18 Undercarriage 18
19

Overturn

19

20

Windshield
Trailer

20

21

Vehicle Defects (two)

1 NO
!

!Roadway Grade

1 LEVEL

!Roadway Alignment

1 STRAIGHT

!Second (2) Sequence of Events

21

)
......

r;;:J

I6

X
~~ ,,. 16 1111 -~
0
/I"
JI.. I 13 112 111 110 9
Phone Number

Emergency Vehicle Use Special Function of MV

1 NONE

Traffic Control Device For This Vehicle !First (1) Sequence of Events

5 TRAFFIC CONTROL SIGNAL

Zip Code

!Vehicle Defects (one)

16 (SPORT) UTILITY VEHICLE

!
ITrafficway

..... r;;:J

Total Lanes

r04

40

Most Damaged Area

Area of Initial Impact

Comm GVWR/GCWR

IPosted Speed

1 NO SPECIAL
FUNCTION

Most Harmful Event

Most Harmful Event Detail

2 COLLISION WITH
NON-FIXED OBJECT

14 COLLISION WITH MOTOR VEH IN

I TRANSPORT
IThird (3) Sequence of Events
I Fourth (4) Sequence of Events

14 COLLISION WITH MOTOR VEH

IN TRANSPORT

Page 1 of 4

I_

1.,.;.
t...

Crash Date

lnme of Crash

lU:l:ll

Vehicle

Motor Vehicle Type

02

1 VEH IN TRANSPORT

Year

Make

2010

NISS

I Reporting Agency Case Number

I Date of Report

11 :04 AM

JUNE 26, 2013

JUNE 26, 2013

I HSMV Crash Report Number

130600794

83950527

1::
I Hit and Run

Veh License Number

7691NF

1 NO

I Model

!State IReg. Expires

Style

I Color

4D

BLU/

FL

Extent of Damage

FEBRUARY 2, 2014

1 NO

JN8AS5MV5AW107307

'Towed Due To Damage Vehicle Removed By

I Est. Damage

4MINOR

!Permanent Reg. IVIN

$500

1 NO

Rotation

DRIVER

Insurance Company (Driver)

i'":

'Insurance Policy Number

21ST CENTURY CENTENNIAL INSURANCE C

Name of Vehicle Owner (Business)

l~

20537952

Current Address

.-:

Zip Code

City & State

2516 S 19TH ST 101

MARIAM MATEEN

FT PIERCE, FL

r.:

34982

Trailer
One:

Licen se Number

State

Reg. Expires

Permanent Reg.

VIN

Year

Make

Length

Axles

Trailer
Two:

License Number

State

Reg. Expires

Permanent Reg.

VIN

Year

Make

Length

Axles

Vehicle
Traveling

On Street, Road, Highway

Direction

Posted Speed

'At Est. Speed

CMV Configuration

Trailer Type (Trailer One)

Comm GVWR/GCWR

213141516

ITrailer Type (Trailer Two)

1
Number

I Haz. Mat. Placard

I Class

14

Comm/Non-Commercial

Vehicle Maneuver Action

TRAFFIC

--

IX x

16

I 13 112 I 11110

....

,_

I Roadway Grade

I~ONT LEFT TURN LANE

Roadway Alignment
,....,......_A::......

1 NO SPECIAL
FUNCTION

INON-FIXED OBJECT

ITRANSPORT

I I Second (2) Sequence of Events

1~1n.

I=

I Emergency Vehicle Use Special Function of MV

IMost Harmful Event

I"> ,...,...,

-- - -

16

Phone Number

1 NO

.t

Traffic Control Device For This Vehicle r rst (1) Sequence of Events

5 TRAFFIC CONTROL SIGNAL

Vehicle Defects (two)

Elt

'

IIX x
14 I 13 112 111110 x
1

1 NONE

ITrafficway

...

213141516

18 Undercarriage 18
19
Overturn
19
20 Windshield 20
Trailer
21
21

Zip Code

!Vehicle Defects (one)

rehicle Body Type

1 PASSENGER CAR

City & State

Motor Carrier Address

'
11

Most Damaged Area

1v s-fietillumb~ ,

llVIOtor Larner .. ame

04

I Cargo Body Type

Area of Initial Impact

Haz. Mat. Release

IT otal Lanes

40

S 25TH STREET

,:

Most Harmful Event Detail

.. 1 WITl-I

1A r n l I IC:lnM WITl-I MnTnl> \/1=1-1 ...

IThird (3) Sequence of Events

I Fourth (4) Sequence of Events

14 COLLISION WITH MOTOR VEH

IN TRANSPORT

I.

J~~..
,.

Person# !Description

01

I Date of Birth

'Vehicle# ' Name

1 DRIVER

01

FRANCES G. CENDEJAS

~s~

874 SW HAMBERLAND AVE

Driver License Number

IDL Type

!Expires

FL

Restraint Systems

2 FEMALE

AUGUST 26, 2019

IAir Bag Deployed

3 SHOULDER AND LAP

BELT USED

2 NOT DEPLOYED

Drivers Actions at Time of Crash (First)

Injury Severity

Ejection

1 NONE

1 NOT EJECTED

'Seating Location Seat

3 NOT
APPLICABLE

' Seating Location Row Seating Location Other

1 LEFT

1 FRONT

1 NOT APPLICABLE
I

Drivers Actions at nme of Crash (Second)

2 OPERATED MV IN CARELESS/NEGLIGENT
MANNER
Drivers Actions at nme of Crash (Fourth)

Drivers Actions at nme of Crash (Third)

34953

3 NO ENDORSEMENT
Eye Protection

3 NO HELMET

2 NO
Zin rn"o

Req. End.

5 E I OPERATOR
relmet Use

I Re-Exam

(772) 353-0019

PORT SAINT LUCIE, FL

!State

C532247838060

I Phone Number

'Sex

AUGUST 26, 1983

Driver Distracted By

Vision Obstruction

7 INATIENTIVE

1 VISION NOT OBSCURED

Drivers Condition at Time of Crash

77 OTHER (EXPLAIN IN NARRATIVE)

Suspected Alcoho l Use 'Alcohol Tested

rlcohol Test Type

rlcohol Test Result BAC

ruspected Drug Use

1 NO

Drug Tested

!
I Drug Test Result

'Drug Test Type

1 NO

Source of Transport to Medical Facility

' EMS Agency Name or ID

Medical Facility Transported To

I EMS Run Number

1 NOT TRANSPORTED

l!J::l~I..,.

Person# I Description

02

I Date of Birth

!Vehicle# I Name

1 DRIVER

02

MARIAM MATEEN

FEBRUARY 2, 1989

2516 S 19TH ST 101

S320540895420
Restraint Systems

3 SHOULDER AND LAP

BELT USED

2 FEMALE

FEBRUARY 2, 2019

' Air Bag Deployed

2 NOT DEPLOYED

Drivers Actions at nme of Crash (First)

34982

I Req. End.

IDL Type

'Expires

FL

5 E I OPERATOR

3 NO ENDORSEMENT

Eye Protection

relmet Use

3 NO HELMET

3 NOT
APPLICABLE

Drivers Actions at TI me of Crash (Second)

1 NO CONTRIBUTING ACTION
Drivers Actions at Time of Crash (Third)

Drivers Actions at nme of Crash (Fourth)

Ejection

1 NONE

1 NOT EJECTED

'

' Seating Location Row Seating Location Other

1 FRONT

1 NOT APPLICABLE

Driver Distracted By

Vision Obstruction

1 NOT DISTRACTED

1 VISION NOT OBSCURED

Drivers Condition at Time of Crash

1 APPARENTLY NORMAL
Suspected Alcohol Use 'Alcohol Tested

'Alcohol Test Type

rlcohol Test Result BAC

15uspected Drug Use

1 NO
Source ofTransport to Medical Facility

HSMV 90010 S

Drug Tested

'Drug Test Type

1 NO
I EMS Agency Name or ID

'EMS Run Number

1 NOT TRANSPORTED

Page 2 of 4

'
'

Injury Severity
reating Location Seat

1 LEFT

2NO
Zip Code

FT PIERCE, FL
!State

'Re-Exam

(772) 318-9188

City & State

Address
Driver License Number

I Phone Number

I Sex

Medical Facility Transported To

Drug Test Result

I
:
''

I
'
:

'

Crash Date

ITime of Crash

JUNE 26, 2013

1~:

IDate of Report

JUNE 26, 2013

11:04AM

I Reporting Agency Case Number

IHSMV Crash Report Number

130600794

83950527

....,.

Person# 'Description

03

IDate of Birth

!Vehicle# IName

3 PASSENGER

02

NUZHAT RASHID

729 SABAL LAKE DRIVE

'Air Bag Deployed

3 SHOULDER AND LAP

BELT USED

I Injury Severity

IEjection

2 FEMALE 1 NONE

1 NOT EJECTED

City& State

Address
Restraint Systems

ISex

MARCH 8, 1953

2 NOT DEPLOYED

Source ofTransport to Medical Facility

'Helmet Use

3 NO HELMET

'EMS Agency Name or ID

Eye Protection

3 NOT
APPLICABLE

'

Zip Code

PORT ST LUCIE, FL
reating Location Seat

3 RIGHT

'EMS Run Number

34986
'Seating Location Row reating Location Other

1 FRONT

1 NOT APPLICABLE
..

..

'Medical Facility Transported To

1 NOT TRANSPORTED
ll'F.!.1:4~6!

On June 26, 2013, I responded to Virginia Avenue and S. 25th Street for a report of a non-injury traffic crash. Prior to my arrival, both vehicles had
moved to a private parking lot. I met with the drivers and obtained their statements. St. Lucie Fire Rescue also responded and obtained refusals for
all parties involved.
Vehicle 1, a 2002 Chrysler van, was driven by Frances Cendejas. Cendejas stated she was traveling north on S. 25th Street and did not see traffic
stopping, in front of her. Cendejas stated she was distracted, due to pain in her right hand, having been slammed in the sliding door of her van.

:
r.

Cendejas was entroute to the hospital to have her hand X-rayed. Cendejas did attempt to stop, but could not, and struck the rear of Vehicle 2.
Cendejas denied injury.

'

Vehicle 2, a 2010 Nissan, was driven by Mariam Seddique. Seddique stated she was stopped in traffic, for the red light at Virginia Avenue. She heard
tires squealing, and then felt the impact of Vehicle 1 hitting the rear of her vehicle. Seddique and her passenger denied injury.
Damage was minimal to both vehicles, and both vehicles were driven from the scene.
1..enaeJas was veroa11y wdrnea.
1:4::::1~ !lm1

=-

ID/Badge Number

8484

::Ill . . . . . .

Rank and Name

I Department

NO RANK D. DANIELS

FORT PIERCE POLICE DEPARTMENT

IType of Department

'
'
'

2 PD

r.

HSMV 90010 S

Page 3 of 4

f.:

I-

HSMV 90010 S

Page 4 of 4