1500001364 - Newton Police Department

Commonwealth of Massachusetts
Number
Motor Vehicle Crash Vehicles
2
Police Report
Police Use Only
Date of Crash Time of Crash
12/20/2015
NEWTON
16:49:00
24HR
<
AT INTERSECTION:
1
4
2
1
3
1
LOCATION
2 Occupants
X Vehicle 1 ___#
q
q Hit/Run
18
Sex____ Lic. Class
5
18
19
Lic. Restrictions
CDL ________
1
TOYOTA
2006
Veh Year______________
Veh Make______________________
Veh Config.
45 MORSELAND AVE
Address _________________________________________________________________
City _________________________________ State______ Zip ___________
02459
NEWTON
City ___________________________________________
State______ Zip ___________
USAA CASUALTY
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Vehicle Travel Direction:
N S X
E W
Responding to Emergency?____
Last
First
Event Sequence
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
25
Age/DOB
See Above
22
2
3
4
1
9
10 Undercarriage
5 11 Totaled
8
7
O
24
1
Towed ____
27
28
29
30
31
32
33
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
Medical Facility
Sex
--------
--- ---
ABRAMS, ADINA
06/18/2006
F
6
99
4
99
0
0
5
1
N/A
ABRAMS, ORLI
45 MORSELAND ROAD
NEWTON, MA 02459
08/09/2001
F
8
99
4
99
0
0
5
1
N/A
X Vehicle 2
q
1
___#
Occupants
q Non-Motorist A
M Lic. Class D
Sex____
18
18
Lic. Restrictions
1
19
Type
CDL ________
Endorsment
14
15
Action
16
Location
17
Condition
q Hit/Run qMoped
5XGT10
PAN
MA
Reg # _____________________________
Reg Type____________
Reg State__________
NISSAN
2003
Veh Year______________
Veh Make______________________
Veh Config.
2
20
VAN
TRAN
HAI
Operator ______________________________________________________
(Same as operator)
Owner __________________________________________________________________
61 TENNYSON STREET
Address _______________________________________________________
Address _________________________________________________________________
MA Zip ___________
WORCESTER
01610
City _________________________________
State______
City ___________________________________________ State______ Zip ___________
COMMERCE
Insurance Company______________________________________________
Vehicle Action Prior to Crash
Last
Vehicle Travel Direction:
First
N S X
E W
Middle
Responding to Emergency?____
N/A
Citation # (If Issued)______________
Last
Event Sequence
2
Most Harmful Event
First
22
2
Driver Contributing Code
Violation 3: Ch______Sec______ Violation 4: Ch______Sec______
Underride/Override
Operator/Non-Motorist
See Above
--------
Sex
Damaged Area Code: (Circle Up to Three)
21
22
2
3
4
1
9
10 Undercarriage
5 11 Totaled
8
7
24
24
19
Towed ____
26
Age/DOB
Middle
23
25
Please fill out for operator and all occupants involved
Address
10
22
22
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Name (Last First Middle)
11
1
12
6
O
45 MORSELAND AVE
NEWTON, MA 02459
MA
1
24
1
26
Address
S82446952
License # __________________________
St ______ DOB/Age __________
8
Middle
23
1
Violation 1: Ch______Sec______ Violation 2: Ch______Sec______
Please Select One
of the Following:
7
Damaged Area Code: (Circle Up to Three)
21
11
22
22
22
1
Please fill out for operator and all occupants involved
1
10
MA
Most Harmful Event
Operator
2
20
Address _______________________________________________________
Middle
Name (Last First Middle)
7
2
ABRAMS
LYNN
S
Owner __________________________________________________________________
First
9
785ND9
PAN
MA
Reg # _____________________________
Reg Type____________
Reg State__________
Operator ______________________________________________________
Last
2
Case Number 1500001364
Citation # (If Issued)______________
6
NOT AT INTERSECTION:
q Moped
Endorsment
1
>
State Police q
Local Police X
q
MBTA Police q
Other:
WALNUT ST
EAST
916
______ ________
_____________________________________________________ _____ _________ __________ ___________________________________________
Route#
Direction
Name
of
Roadway/Street
Route#
Direction
Address
#
Name of Roadway/Street
_________________________________________________________________________ __________________________________________________________________________
At
___ ___ ___ l ___ or __________________
________Feet N S E W of
______ ________
_____________________________________________________
Mile Marker
Exit Number
Route# Direction
Name of Intersecting Roadway/Street
_________________________________________________________________________
________Feet N S E W of
Also at Intersection with
_______ _______________________________
Route#
Intersecting Roadway/Street
________Feet N S E W of
______ ________
_____________________________________________________
___________________________________________
Route# Direction
Name of Intersecting Roadway/Street
Landmark
License # __________________________ St _____ DOB/Age ___________
4
RMV Document Number
Number Speed Limit 5
Injured Latitude
Longitude
0
City/Town
27
28
29
30
O
6
31
32
33
Seat Safety Airbag Airbag Eject Trap Injury Transp.
Pos. System Status Switch Code Code Status Code
--- --- 1
4
99
0
0
5
1
Medical Facility
N/A
2
13
= Direction
ie:
Crash Diagram:
1
= Vehicle 1
1
2
=Vehicle 2
= Pedestrian
2
If Crash Did Not Occur
on a Public Way:
r Off-Street Parking Lot
r Garage
r Mall/Shopping Center
r Other Private Way
Indicate North by Arrow
Crash Narrative:
__________________________________________________________________________________________________________________________________________________
Vehicle 1 was parked in a parking stall facing Eastbound in the Whole Foods parking lot located at 916 Walnut
__________________________________________________________________________________________________________________________________________________
Street, Newton.
Vehicle 1 (Ma Reg: 785ND9) was occupied by 2 females waiting for their mother to
__________________________________________________________________________________________________________________________________________________
return from the store. Both parties stated they observed a light brown SUV back out of a spot across from
__________________________________________________________________________________________________________________________________________________
their vehicle and crash into their rear driver side.
Both parties stated the vehicle then left the area with
__________________________________________________________________________________________________________________________________________________
out stopping.
Both parties stated the registration for the vehicle was Ma Reg: 5XGT10.
No injuries
__________________________________________________________________________________________________________________________________________________
reported.
I observed minor damage above the driver side rear tire/fender area.
__________________________________________________________________________________________________________________________________________________
Vehicle 2 returned to the scene at the request of Newton PD.
The driver of Vehicle 2 apoligized for leaving
__________________________________________________________________________________________________________________________________________________
and stated he did not realize he hit Vehicle 1
when he was backing out of his parking spot.
I observed
__________________________________________________________________________________________________________________________________________________
minor fresh damage to
the rear driver side fender/break light area of Vehicle 2.
__________________________________________________________________________________________________________________________________________________
(Continued on next page)
__________________________________________________________________________________________________________________________________________________
W itnesses:
Name (Last, First, Middle)
Address
Phone #
Statement
Property Damage:
Owner (Last, First, Middle)
Address
Phone #
34-Type
Truck and Bus Information:
Registration # ___________________________(From Vehicle Section)
Description of Damaged Property
35
Carrier Name ___________________________________________________________________________________________ Carrier Issuing Authority Code
Address___________________________________________________________ City________________________________
St________
Zip___________
US DOT #: ______________________ State Number________________________ Issuing State ________ ICC #:_____________________ Interstate
Cargo Body Type Code
37
Gross Vehicle Weight
36
38
Trailer Reg #:_______________________ Reg Type__________ Reg State _________ Reg Year__________ Trailer Length
39
Hazmat Information:
Placard
40
Material 1 digit #
41
Material Name______________________________ Material 4 digit # _____________ Release code
42
MICHAEL R GAUDET
12/20/2015
_________________________________________________________________________________________________________________________________________________
Police Officer Name (Please Print)
Signature
ID/Badge #
Department
Precinct/Barracks
Date
NEWTON POLICE DEPARTMENT
CDP1 11 . 24. 00
= Direction
ie:
Crash Diagram:
1
= Vehicle 1
1
2
=Vehicle 2
= Pedestrian
2
If Crash Did Not Occur
on a Public Way:
r Off-Street Parking Lot
r Garage
r Mall/Shopping Center
r Other Private Way
Indicate North by Arrow
Crash Narrative:
__________________________________________________________________________________________________________________________________________________
I asked Whole Foods staff if they had footage of the accident.
Whole Foods stated they have no surveillance
__________________________________________________________________________________________________________________________________________________
footage in their parking lot.
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________
W itnesses:
Name (Last, First, Middle)
Address
Phone #
Statement
Property Damage:
Owner (Last, First, Middle)
Address
Phone #
34-Type
Truck and Bus Information:
Registration # ___________________________(From Vehicle Section)
Description of Damaged Property
35
Carrier Name ___________________________________________________________________________________________ Carrier Issuing Authority Code
Address___________________________________________________________ City________________________________
St________
Zip___________
US DOT #: ______________________ State Number________________________ Issuing State ________ ICC #:_____________________ Interstate
Cargo Body Type Code
37
Gross Vehicle Weight
36
38
Trailer Reg #:_______________________ Reg Type__________ Reg State _________ Reg Year__________ Trailer Length
39
Hazmat Information:
Placard
40
Material 1 digit #
41
Material Name______________________________ Material 4 digit # _____________ Release code
42
MICHAEL R GAUDET
12/20/2015
_________________________________________________________________________________________________________________________________________________
Police Officer Name (Please Print)
Signature
ID/Badge #
Department
Precinct/Barracks
Date
NEWTON POLICE DEPARTMENT
CDP1 11 . 24. 00