08728 PERRYSBURG TOWNSHIP POLICE 03

Transcription

1 LOCAL INORMATION * CRASH SEVERITY HIT/SKIP ATAL - SVED 2 - INJURY 2 - UNSVED 3 - PDO REPORTING AGENCY NCIC * REPORTING AGENCY NAME * PHOTOS TAKEN PDO UNDER UNIT IN ERROR PRIVATE NUMBER O STATE PROPERTY UNITS 98- ANIMAL OH-2 OH-P REPORTABLE 99-UNKNOWN OH-3 OTHER DLAR AMOUNT VILLAGE * TOWNSHIP * PERRYSBURG TWP CITY, VILLAGE, TOWNSHIP * COUNTY * 87 CITY * CRASH DATE * TIME O CRASH DAY O WEEK Thu DEGREES / MINUTES / SECONDS DECIMAL DEGREES O LATITUDE LONGITUDE LATITUDE O / // O / // R ROADWAY DIVISION DIVIDED LANE DIRECTION O TRAVEL NUMBER O THRU LANES ROAD TYPES OR MILEPOST 2 DIVIDED N - NORTHBOUND E - EASTBOUND AL - ALLEY CR - CIRCLE W UNDIVIDED S - SOUTHBOUND W - WESTBOUND AV - AVENUE CT - COURT BL - BOULEVARD DR - DRIVE SR LOCATION ROUTE NUMBER LOC PREI LOCATION ROAD NAME LOCATION 795 ROUTE N,S, TYPE E,W, LONGITUDE HE - HEIGHTS HW- HIGHWAY LA - LANE LOCATION ROAD TYPE 2 MP - MILEPOST PK - PARKWAY PI - PIKE ROUTE TYPES PL - PLACE RD - ROAD SQ - SQUARE IR - INTERSTATE ROUTE ( INC. TURNPIKE ) US - US ROUTE SR - STATE ROUTE DISTANCE ROM REERENCE DIR ROM RE REERENCE ROUTE NUMBER RE PREI REERENCE NAME ( ROAD, MILEPOST, HOUSE # ) O REERENCE MILES N,S, ROUTE N,S, EET E,W, W YARDS TYPE E,W, LIME CITY 250 CRASH LOCATION REERENCE POINT USED 0 - NOT AN INTERSECTION - IVE POINT, OR MORE - RAILWAY GRADE CROSSING - INTERSECTION INTERSECTION - OUR-WAY INTERSECTION 07 - ON RAMP 2 - SHARED-USE PATHS OR TRAILS 2 - MILE POST RELATED 3 - HOUSE NUMBER - T-INTERSECTION 08 - O RAMP - Y-INTERSECTION - CROSSOVER ROAD CONTOUR - STRAIGHT LEVEL 2 - STRAIGHT GRADE 3 - CURVE LEVEL MANNER 2O CRASH CLISION/ IMPACT - NOT CLISION BETWEEN TWO MOTOR VEHICLES IN TRANSPORT ROAD SURACE OHIO - CONCRETE 2 - BLACKTOP, BITUMINOUS, ASPHALT 3 - BRICK/ BLOCK TRAIC CRASH REPORT PERRYSBURG TOWNSHIP PICE CURVE GRADE - TRAIC CIRCLE/ROUNDABOUT REAR END 3 - HEAD ON 4 - REAR TO REAR 4 - SLAG, GRAVEL STONE 5 - DIRT 6 - OTHER ROAD CONDITIONS 5 - BACKING 6 - ANGLE 7 - SIDESWIPE, SAME DIRECTION LIGHT CONDITIONS 0 - DRIVEWAY/ ALLEY ACCESS 8 - SIDESWIPE, OPPOSITE DIRECTION - DAYLIGHT 2 - DAWN 3 - DUSK 0 - DRY - WET - SNOW - ICE WEATHER 4 - DARK - LIGHTED ROADWAY - SAND, MUD, DIRT, OIL, GRAVEL - WATER ( STANDING, MOVING ) 07 - SLUSH 08 - DEBRIS * - CLEAR 2 - CLOUDY 3 - OG, SMOG, SMOKE 4 - RAIN 6 - SNOW 5 - DARK - ROADWAY NOT LIGHTED ST - STREET TE - TERRACE TL- TRAIL LOCATION O IRST - ON ROADWAY 2 - ON SHOULDER 3 - IN MEDIAN 4 - ON ROADSIDE - RUT, HES, BUMPS, UNEVEN PAVEMANT * 0 - OTHER 5 - SLEET, HAIL 6 - DARK - UNKNOWN ROADWAY LIGHTING 7 - GLARE * 8 - OTHER 7 - SEVERE CROSSWINDS 8 - BLOWING SAND, SOIL, DIRT, SNOW 9 - OTHER/ UNKNOWN * CONDITION ONLY TYPE O WORK ZONE LOCATION O CRASH IN WORK ZONE WORKERS PRESENT WORK - LANE CLOSURE 4 - INTERMITTENT OR MOVING WORK - BEORE THE IRST WORK ZONE WARNING SIGN 2 LAW ENORCEMENT PRESENT ZONE ( OICER/ VEHICLE ) 2 - LANE SHIT/ CROSSOVER 5 - OTHER 2 - ADVANCE WARNING AREA RELATED LAW ENORCEMENT PRESENT 3 - WORK ON SHOULDER OR MEDIAN 3 - TRANSITION AREA ( VEHICLE ONLY ) SCHO ZONE RELATED WA - WAY CR - NUMBERED COUNTY ROUTE TR - NUMBERED TOWNSHIP ROUTE RD REERENCE ROAD TYPE ON GORE 6 - OUTSIDE TRAICWAY * CONDITION ONLY SCHO BUS RELATED YES, SCHO BUS DIRECTLY INVVED YES, SCHO BUS INDIRECTLY INVVED 4 - ACTIVITY AREA 5 - TERMINATION AREA NARRATIVE All vehicles involved were traveling westbound on SR795 west of Lime City Rd. The driver of Unit # and Unit # 2 both advised that they were forced to come to a complete stop in the roadway due to congestion caused by the upcoming lane closure. The driver of unit # 3, Allison J Perry, stated that she was unable to stop in time and struck the rear of unit #2. Unit #2 was then pushed forward into the rear of Unit #. No injuries reported. No vehicles towed. Perry was cited for ORC 45.2A (MM). This is her second moving citation within 2 months (speed /4). She was issued a court date of 0/28/2 at 700hrs should she choose to appear. DIAGRAM WRITE AN ''N'' ON THE COMPASS DIAGRAM TO INDICATE THE DIRECTION O NORTH REPORT TAKEN BY SUPPLEMENT ( CORRECTION OR ADDITION TO PICE AGENCY AN EISTING REPORT SENT TO ODPS ) OTHER INVESTIGATION TIME DATE CRASH REPORTED TIME CRASH REPORTED DISPATCH TIME ARRIVAL TIME TIME CLEARED TOTAL MINUTES 0076 OICER'S NAME * OICER'S BADGE NUMBER CHECKED BY KATAIAS, KIMBERLY HSY700 OH ( REV 0/2 ) 07 LENTZ, AARON L Page: of 7

2 UNIT UNIT NUMBER 0 DESJARDIN JAEGAR J OWNER NAME: LAST, IRST, MIDDLE OWNER PHONE NUMBER - INC. AREA CODE OWNER ADDRESS: CITY, STATE, ZIP 72 US HIGHWAY 23 GIBSONBURG Ohio LP STATE LICENSE PLATE NUMBER VEHICLE IDENTIICATION NUMBER OH US9888 G2WP52K72258 # 0 OCCUPANTS VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE COR 200 PONT GRA SIL PROO O INSURANCE COMPANY PICY NUMBER TOWED BY INSURANCE SHOWN AMERICAN AMILY INSURANCE PPAOH DAMAGE SCALE - NONE 2 - MINOR 3 - UNCTIONAL 4 - DISABLING DAMAGED AREA RONT REAR CARRIER NAME, CARRIER PHONE - INCLUDE AREA CODE 2 US HM PLACARD ID NO. HM CLASS NUMBER VEHICLE WEIGHT LOCATION PRIOR TO IMPACT SPECIAL UNCTION 0 PRE - CRASH ACTIONS GVWR / GCWR - LESS THAN OR EQUAL TO 0K LBS. 2-0,00 TO 26,000 LBS 3 - MORE THAN 26,000 LBS. HAZARDOUS MATERIAL RELEASED 0 - INTERSECTION - MARKED CROSSWALK - INTERSECTION - NO CROSSWALK - INTERSECTION - OTHER - MIDBLOCK - MARKED CROSSWALK - TRAVEL LANE - OTHER LOCATION - BICYCLE LANE 07 - SHOULDER / ROADSIDE 08 - SIDEWALK - MEDIAN / CROSSING ISLAND 0 - DRIVEWAY ACCESS - SHARED - USE PATH OR TRAIL 2 - NON - TRAICWAY AREA 0 - NONE - TAI - RENTAL TRUCK ( OVER 0K LBS ) - BUS - SCHO ( PUBLIC OR PRIVATE ) - BUS - TRANSIT - BUS - CHARTER 07 - BUS - SHUTTLE 08 - BUS - OTHER 0 - STRAIGHT AHEAD - BACKING - CHANGING LANES - OVERTAKING / PASSING - MAKING RIGHT TURN - MAKING LET TURN TYPE O USE - PERSONAL 2 - COMMERCIAL 3 - GOVERNMENT IN EMERGENCY RESPONSE - AMBULANCE 0 - IRE - HIGHWAY / MAINTENANCE 2 - MILITARY 3 - PICE 4 - PUBLIC UTILITY 5 - OTHER GOVERNMENT 6 - CONSTRUCTION EQUIP MAKING U - TURN 08 - ENTERING TRAIC LANE - LEAVING TRAIC LANE 0 - PARKED - SLOWING OR STOPPED IN TRAIC 2 - DRIVERLESS CARGO 0 BODY TYPE 0 - NO CARGO BODY TYPE / NOT APPLICABLE - BUS / VAN ( 9-5 SEATS, INC DRIVER ) - BUS ( 6 + SEATS, INC DRIVER ) - VEHICLE TOWING ANOTHER VEHICLE - LOGGING - INTERMODAL CONTAINER CHASSIS 07 - CARGO VAN / ENCLOSED BO 08 - GRAIN, CHIPS, GRAVEL UNIT TYPE PASSENGER VEHICLES ( LESS THAN 9 PASSENGERS ) 0 - SUB - COMPACT - COMPACT - MID SIZE OR HIT / SKIP - ULL SIZE - MINIVAN - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN MOTORIZED BICYCLE - SNOWMOBILE / ATV 2 - OTHER PASSENGER VEHICLE 7 - ARM VEHICLE 8 - ARM EQUIPTMENT 9 - MOTORHOME 20 - G CART 2 - TRAIN 22 - OTHER ( EPLAIN IN NARRATIVE ) 3 - NEGOTIATING A CURVE ACTION - PE 0 - CARGO TANK - LAT BED 2 - DUMP MOST DAMAGED AREA IMPACT AREA 3 - CONCRETE MIER 4 - AUTO TRANSPORTER 5 - GARBAGE / REUSE HAS HM PLACARD TRAICWAY DESCRIPTION 4 - TWO - WAY, NOT DIVIDED 2 - TWO - WAY, NOT DIVIDED, CONTINUOUS LET TURN LANE 3 - TWO - WAY, DIVIDED, UNPROTECTED ( PAINTED OR GRASS > 4 T. ) MEDIAN 4 - TWO - WAY, DIVIDED, POSITIVE MEDIAN BARRIER 5 - ONE - WAY TRAICWAY HIT / SKIP UNIT MED / HEAVY TRUCKS OR COMBO UNITS > 0K LBS 0 - NONE 3 - SINGLE UNIT TRUCK OR VAN 2ALE, 6 TIRES 4 - SINGLE UNIT TRUCK; 3 + ALES 5 - SINGLE UNIT TRUCK / TRAILER 6 - TRUCK / TRACTOR ( BOBTAIL ) 7 - TRACTOR / SEMI - TRAILER 8 - TRACTOR / DOUBLE 9 - TRACTOR / TRIPLES 20 - OTHER MED / HEAVY VEHICLE - CENTER RONT - RIGHT RONT - RIGHT SIDE - RIGHT REAR - REAR CENTER 07 - LET REAR 08 - LET SIDE - LET RONT 0 - TOP AND WINDOWS - UNDERCARRIAGE 2 - LOAD / TRAILER 3 - TOTAL ( ALL AREAS ) 5 - ENTERING OR CROSSING SPECIIED LOCATION 6 - WALKING, RUNNING, JOGGING, PLAYING, CYCLING 7 - WORKING 8 - PUSHING VEHICLE 9 - APPROACHING OR LEAVING VEHICLE 20 - STANDING BUS / VAN / LIMO ( 9 OR MORE INCLUDING DRIVER 2 - BUS / VAN ( 9-5 SEATS, INC DRIVER ) 22 - BUS ( 6 + SEATS, INC DRIVER ) 23 - ANIMAL WITH RIDER 24 - ANIMAL WITH BUGGY, WAGON, SURREY 25 - BICYCLE / PEDACYCLIST 26 - PEDESTRIAN / SKATER 27 - OTHER 4 ACTION - NON - CONTACT 2 - NON - CLISION 3 - STRIKING 4 - STRUCK 5 - STRIKING / STRUCK 2 - OTHER ACTION CONTRIBUTING CIRCUMSTANCES NONE - AILURE TO YIELD - RAN RED LIGHT - RAN STOP SIGN - ECEEDED SPEED LIMIT - UNSAE SPEED 07 - IMPROPER TURN 08 - LET O CENTER - LOWED TO CLOSELY / ACDA 0 - IMPROPER LANE CHANGE / PASSING / O ROAD - IMPROPER BACKING 2 - IMPROPER START ROM PARKED POSITION 3 - STOPPED OR PARKED ILLEGALLY 4 - OPERATING VEHICLE IN NEGLIGENT MANNER 5 - SWERVING TO AVOID ( DUE TO ETERNAL CONDITIONS ) 6 - WRONG SIDE / WRONG WAY 7 - AILURE TO CONTR 8 - VISION OBSTRUCTION 9 - OPERATING DEECTIVE EQUIPTMENT 20 - LOAD SHITING / ALLING / SPILLING 2 - OTHER IMPROPER ACTION 22 - NONE 23 - IMPROPER CROSSING 24 - DARTING 25 - LYING AND / OR ILLEGALLY IN ROADWAY 26 - AILURE TO YIELD RIGHT O WAY 27 - NOT VISIBLE ( DARK CLOTHING ) 28 - INATTENTIVE 29 - AILURE TO OBEY TRAIC SIGNS / SIGNALS / OICER 30 - WRONG SIDE O THE ROAD 3 - OTHER ACTION VEHICLE DEECTS 0 - TURN SIGNALS - HEAD LAMPS - TAIL LAMPS - BRAKES - STEERING - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPTMENT DEECTIVE - MOTOR TROUBLE 0 - DISABLED ROM PRIOR ACCIDENT - OTHER DEECTS SEQUENCE O S IRST MOST NON - CLISION S 0 - OVERTURN / RLOVER - IRE / EPLOSION - IMMERSION - JACKNIE - CARGO / EQUIPTMENT LOSS OR SHIT - EQUIPTMENT AILURE ( BLOWN TIRE, BRAKE AILURE, ECT ) 07 - SEPERATION O UNITS 08 - RAN O ROAD RIGHT - RAN O ROAD LET 0 - CROSS MEDIAN - CROSS CENTER LINE OPPOSITE DIRECTION O TRAVEL 2 - DOWNHILL RUNAWAY 3 - OTHER NON - CLISION CLISION WITH PERSON, VEHICLE OR OBJECT NOT IED 4 - PEDESTRIAN 2 - PARKED MOTOR VEHICLE 5 - PEDALCYCLE 22 - WORK ZONE MAINTENANCE EQUIPTMENT 6 - RAILWAY VEHICLE ( TRAIN, ENGINE ) 23 - STRUCK BY ALLING, SHITING CARGO 7 - ANIMAL - ARM OR ANYTHING SET IN MOTION BY A MOTOR VEHICLE 8 - ANIMAL - DEER 2 MOVABLE OBJECT 9 - ANIMAL - OTHER 20 - MOTOR VEHICLE IN TRANSPORT CLISION WITH IED OBJECT 25 - IMPACT ATTENUATOR / CRASH CUSHION 26 - BRIDGE OVERHEAD STRUCTURE 27 - BRIDGE PIER OR ABUTMENT 28 - BRIDGE PARAPET 29 - BRIDGE RAIL 30 - GUARDRAIL ACE 3 - GUARDRAIL END 32 - PORTABLE BARRIER 33 - MEDIAN CABLE BARRIER 34 - MEDIAN GUARDRAIL BARRIER 35 - MEDIAN CONCRETE BARRIER 36 - MEDIAN OTHER BARRIER 37 - TRAIC SIGN POST 38 - OVERHEAD SIGN POST 39 - LIGHT / LUMINARIES SUPPORT 40 - UTILITY PE POST, PE OR SUPPORT 42 - CULVERT 43 - CURB 44 - DITCH 45 - EMBANKMENT 46 - ENCE 47 - MAILBO 48 - TREE 49 - IRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPTMENT 5 - WALL, BUILDING, TUNNEL 52 - OTHER IED OBJECT UNIT SPEED POSTED SPEED 0 55 STATED ESTIMATED TRAIC CONTR 0 - NO CONTRS 07 - RAILROAD CROSSBUCKS - STOP SIGN 08 - RAILROAD LASHERS - YIELD SIGN - RAILROAD GATES - TRAIC SIGNAL 0 - CONSTRUCTION BARRICADE - TRAIC LASHERS - PERSON ( LAGGER, OICER ) - SCHO ZONE 2 - PAVEMENT MARKINGS 3 - CROSSWALK LINES 4 - WALK / DON'T WALK 5 - OTHER 6 - NOT REPORTED UNIT DIRECTION 2 3 ROM TO 4 - NORTH 2 - SOUTH 3 - EAST 4 - WEST 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST Page: 2 of 7 HSY83 OHU ( REV 0/2 )

3 UNIT UNIT NUMBER HARDER THERESA LYNN OWNER NAME: LAST, IRST, MIDDLE OWNER PHONE NUMBER - INC. AREA CODE OWNER ADDRESS: CITY, STATE, ZIP 4 HERTORD CT MAUMEE Ohio LP STATE LICENSE PLATE NUMBER VEHICLE IDENTIICATION NUMBER OH EET9860 2MDK3KC9BBA89584 # 0 OCCUPANTS VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE COR 20 ORD EDG SIL PROO O INSURANCE COMPANY PICY NUMBER TOWED BY INSURANCE SHOWN AMMERICAN COMMERCE ACPA0634 DAMAGE SCALE - NONE 2 - MINOR 3 - UNCTIONAL 4 - DISABLING DAMAGED AREA RONT REAR CARRIER NAME, CARRIER PHONE - INCLUDE AREA CODE US HM PLACARD ID NO. HM CLASS NUMBER VEHICLE WEIGHT LOCATION PRIOR TO IMPACT SPECIAL UNCTION 0 PRE - CRASH ACTIONS GVWR / GCWR - LESS THAN OR EQUAL TO 0K LBS. 2-0,00 TO 26,000 LBS 3 - MORE THAN 26,000 LBS. HAZARDOUS MATERIAL RELEASED 0 - INTERSECTION - MARKED CROSSWALK - INTERSECTION - NO CROSSWALK - INTERSECTION - OTHER - MIDBLOCK - MARKED CROSSWALK - TRAVEL LANE - OTHER LOCATION - BICYCLE LANE 07 - SHOULDER / ROADSIDE 08 - SIDEWALK - MEDIAN / CROSSING ISLAND 0 - DRIVEWAY ACCESS - SHARED - USE PATH OR TRAIL 2 - NON - TRAICWAY AREA 0 - NONE - TAI - RENTAL TRUCK ( OVER 0K LBS ) - BUS - SCHO ( PUBLIC OR PRIVATE ) - BUS - TRANSIT - BUS - CHARTER 07 - BUS - SHUTTLE 08 - BUS - OTHER 0 - STRAIGHT AHEAD - BACKING - CHANGING LANES - OVERTAKING / PASSING - MAKING RIGHT TURN - MAKING LET TURN TYPE O USE - PERSONAL 2 - COMMERCIAL 3 - GOVERNMENT IN EMERGENCY RESPONSE - AMBULANCE 0 - IRE - HIGHWAY / MAINTENANCE 2 - MILITARY 3 - PICE 4 - PUBLIC UTILITY 5 - OTHER GOVERNMENT 6 - CONSTRUCTION EQUIP MAKING U - TURN 08 - ENTERING TRAIC LANE - LEAVING TRAIC LANE 0 - PARKED CARGO BODY TYPE - SLOWING OR STOPPED IN TRAIC 2 - DRIVERLESS 0 - NO CARGO BODY TYPE / NOT APPLICABLE - BUS / VAN ( 9-5 SEATS, INC DRIVER ) - BUS ( 6 + SEATS, INC DRIVER ) - VEHICLE TOWING ANOTHER VEHICLE - LOGGING - INTERMODAL CONTAINER CHASSIS 07 - CARGO VAN / ENCLOSED BO 08 - GRAIN, CHIPS, GRAVEL UNIT TYPE PASSENGER VEHICLES ( LESS THAN 9 PASSENGERS ) 0 - SUB - COMPACT - COMPACT - MID SIZE OR HIT / SKIP - ULL SIZE - MINIVAN - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN MOTORIZED BICYCLE - SNOWMOBILE / ATV 2 - OTHER PASSENGER VEHICLE 7 - ARM VEHICLE 8 - ARM EQUIPTMENT 9 - MOTORHOME 20 - G CART 2 - TRAIN 22 - OTHER ( EPLAIN IN NARRATIVE ) 3 - NEGOTIATING A CURVE ACTION - PE 0 - CARGO TANK - LAT BED 2 - DUMP MOST DAMAGED AREA IMPACT AREA 3 - CONCRETE MIER 4 - AUTO TRANSPORTER 5 - GARBAGE / REUSE HAS HM PLACARD TRAICWAY DESCRIPTION 4 - TWO - WAY, NOT DIVIDED 2 - TWO - WAY, NOT DIVIDED, CONTINUOUS LET TURN LANE 3 - TWO - WAY, DIVIDED, UNPROTECTED ( PAINTED OR GRASS > 4 T. ) MEDIAN 4 - TWO - WAY, DIVIDED, POSITIVE MEDIAN BARRIER 5 - ONE - WAY TRAICWAY HIT / SKIP UNIT MED / HEAVY TRUCKS OR COMBO UNITS > 0K LBS 0 - NONE 3 - SINGLE UNIT TRUCK OR VAN 2ALE, 6 TIRES 4 - SINGLE UNIT TRUCK; 3 + ALES 5 - SINGLE UNIT TRUCK / TRAILER 6 - TRUCK / TRACTOR ( BOBTAIL ) 7 - TRACTOR / SEMI - TRAILER 8 - TRACTOR / DOUBLE 9 - TRACTOR / TRIPLES 20 - OTHER MED / HEAVY VEHICLE - CENTER RONT - RIGHT RONT - RIGHT SIDE - RIGHT REAR - REAR CENTER 07 - LET REAR 08 - LET SIDE - LET RONT 0 - TOP AND WINDOWS - UNDERCARRIAGE 2 - LOAD / TRAILER 3 - TOTAL ( ALL AREAS ) 5 - ENTERING OR CROSSING SPECIIED LOCATION 6 - WALKING, RUNNING, JOGGING, PLAYING, CYCLING 7 - WORKING 8 - PUSHING VEHICLE 9 - APPROACHING OR LEAVING VEHICLE 20 - STANDING BUS / VAN / LIMO ( 9 OR MORE INCLUDING DRIVER 2 - BUS / VAN ( 9-5 SEATS, INC DRIVER ) 22 - BUS ( 6 + SEATS, INC DRIVER ) 23 - ANIMAL WITH RIDER 24 - ANIMAL WITH BUGGY, WAGON, SURREY 25 - BICYCLE / PEDACYCLIST 26 - PEDESTRIAN / SKATER 27 - OTHER 5 ACTION - NON - CONTACT 2 - NON - CLISION 3 - STRIKING 4 - STRUCK 5 - STRIKING / STRUCK 2 - OTHER ACTION CONTRIBUTING CIRCUMSTANCES NONE - AILURE TO YIELD - RAN RED LIGHT - RAN STOP SIGN - ECEEDED SPEED LIMIT - UNSAE SPEED 07 - IMPROPER TURN 08 - LET O CENTER - LOWED TO CLOSELY / ACDA 0 - IMPROPER LANE CHANGE / PASSING / O ROAD - IMPROPER BACKING 2 - IMPROPER START ROM PARKED POSITION 3 - STOPPED OR PARKED ILLEGALLY 4 - OPERATING VEHICLE IN NEGLIGENT MANNER 5 - SWERVING TO AVOID ( DUE TO ETERNAL CONDITIONS ) 6 - WRONG SIDE / WRONG WAY 7 - AILURE TO CONTR 8 - VISION OBSTRUCTION 9 - OPERATING DEECTIVE EQUIPTMENT 20 - LOAD SHITING / ALLING / SPILLING 2 - OTHER IMPROPER ACTION 22 - NONE 23 - IMPROPER CROSSING 24 - DARTING 25 - LYING AND / OR ILLEGALLY IN ROADWAY 26 - AILURE TO YIELD RIGHT O WAY 27 - NOT VISIBLE ( DARK CLOTHING ) 28 - INATTENTIVE 29 - AILURE TO OBEY TRAIC SIGNS / SIGNALS / OICER 30 - WRONG SIDE O THE ROAD 3 - OTHER ACTION VEHICLE DEECTS 0 - TURN SIGNALS - HEAD LAMPS - TAIL LAMPS - BRAKES - STEERING - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPTMENT DEECTIVE - MOTOR TROUBLE 0 - DISABLED ROM PRIOR ACCIDENT - OTHER DEECTS SEQUENCE O S IRST MOST CLISION WITH PERSON, VEHICLE OR OBJECT NOT IED 4 - PEDESTRIAN 2 - PARKED MOTOR VEHICLE 5 - PEDALCYCLE 22 - WORK ZONE MAINTENANCE EQUIPTMENT 6 - RAILWAY VEHICLE ( TRAIN, ENGINE ) 23 - STRUCK BY ALLING, SHITING CARGO 7 - ANIMAL - ARM OR ANYTHING SET IN MOTION BY A MOTOR VEHICLE 8 - ANIMAL - DEER 2 MOVABLE OBJECT 9 - ANIMAL - OTHER 20 - MOTOR VEHICLE IN TRANSPORT NON - CLISION S 0 - OVERTURN / RLOVER - IRE / EPLOSION - IMMERSION - JACKNIE - CARGO / EQUIPTMENT LOSS OR SHIT CLISION WITH IED OBJECT 25 - IMPACT ATTENUATOR / CRASH CUSHION 26 - BRIDGE OVERHEAD STRUCTURE 27 - BRIDGE PIER OR ABUTMENT 28 - BRIDGE PARAPET 29 - BRIDGE RAIL 30 - GUARDRAIL ACE 3 - GUARDRAIL END 32 - PORTABLE BARRIER - EQUIPTMENT AILURE ( BLOWN TIRE, BRAKE AILURE, ECT ) 07 - SEPERATION O UNITS 08 - RAN O ROAD RIGHT - RAN O ROAD LET 33 - MEDIAN CABLE BARRIER 34 - MEDIAN GUARDRAIL BARRIER 35 - MEDIAN CONCRETE BARRIER 36 - MEDIAN OTHER BARRIER 37 - TRAIC SIGN POST 38 - OVERHEAD SIGN POST 39 - LIGHT / LUMINARIES SUPPORT 40 - UTILITY PE 0 - CROSS MEDIAN - CROSS CENTER LINE OPPOSITE DIRECTION O TRAVEL 2 - DOWNHILL RUNAWAY 3 - OTHER NON - CLISION POST, PE 48 - TREE OR SUPPORT 49 - IRE HYDRANT 42 - CULVERT 50 - WORK ZONE MAINTENANCE 43 - CURB EQUIPTMENT 44 - DITCH 5 - WALL, BUILDING, TUNNEL 45 - EMBANKMENT 52 - OTHER IED OBJECT 46 - ENCE 47 - MAILBO UNIT SPEED POSTED SPEED 0 55 STATED ESTIMATED TRAIC CONTR 0 - NO CONTRS 07 - RAILROAD CROSSBUCKS - STOP SIGN 08 - RAILROAD LASHERS - YIELD SIGN - RAILROAD GATES - TRAIC SIGNAL 0 - CONSTRUCTION BARRICADE - TRAIC LASHERS - PERSON ( LAGGER, OICER ) - SCHO ZONE 2 - PAVEMENT MARKINGS 3 - CROSSWALK LINES 4 - WALK / DON'T WALK 5 - OTHER 6 - NOT REPORTED UNIT DIRECTION 2 3 ROM TO 4 - NORTH 2 - SOUTH 3 - EAST 4 - WEST 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST Page: 3 of 7 HSY83 OHU ( REV 0/2 )

4 UNIT UNIT NUMBER PERRY TERRY E OWNER NAME: LAST, IRST, MIDDLE OWNER PHONE NUMBER - INC. AREA CODE OWNER ADDRESS: CITY, STATE, ZIP 3662 LIBBY RD PERRYSBURG Ohio 4355 LP STATE LICENSE PLATE NUMBER VEHICLE IDENTIICATION NUMBER OH P5335 MCU4KA57446 # OCCUPANTS VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL VEHICLE COR 20 ORD ECP RED PROO O INSURANCE COMPANY PICY NUMBER TOWED BY INSURANCE SHOWN HOME OWNERS INS CO DAMAGE SCALE - NONE 2 - MINOR 3 - UNCTIONAL 4 - DISABLING DAMAGED AREA RONT REAR CARRIER NAME, CARRIER PHONE - INCLUDE AREA CODE US HM PLACARD ID NO. HM CLASS NUMBER VEHICLE WEIGHT LOCATION PRIOR TO IMPACT SPECIAL UNCTION 0 PRE - CRASH ACTIONS 0 GVWR / GCWR - LESS THAN OR EQUAL TO 0K LBS. 2-0,00 TO 26,000 LBS 3 - MORE THAN 26,000 LBS. HAZARDOUS MATERIAL RELEASED 0 - INTERSECTION - MARKED CROSSWALK - INTERSECTION - NO CROSSWALK - INTERSECTION - OTHER - MIDBLOCK - MARKED CROSSWALK - TRAVEL LANE - OTHER LOCATION - BICYCLE LANE 07 - SHOULDER / ROADSIDE 08 - SIDEWALK - MEDIAN / CROSSING ISLAND 0 - DRIVEWAY ACCESS - SHARED - USE PATH OR TRAIL 2 - NON - TRAICWAY AREA 0 - NONE - TAI - RENTAL TRUCK ( OVER 0K LBS ) - BUS - SCHO ( PUBLIC OR PRIVATE ) - BUS - TRANSIT - BUS - CHARTER 07 - BUS - SHUTTLE 08 - BUS - OTHER 0 - STRAIGHT AHEAD - BACKING - CHANGING LANES - OVERTAKING / PASSING - MAKING RIGHT TURN - MAKING LET TURN TYPE O USE - PERSONAL 2 - COMMERCIAL 3 - GOVERNMENT IN EMERGENCY RESPONSE - AMBULANCE 0 - IRE - HIGHWAY / MAINTENANCE 2 - MILITARY 3 - PICE 4 - PUBLIC UTILITY 5 - OTHER GOVERNMENT 6 - CONSTRUCTION EQUIP MAKING U - TURN 08 - ENTERING TRAIC LANE - LEAVING TRAIC LANE 0 - PARKED - SLOWING OR STOPPED IN TRAIC 2 - DRIVERLESS CARGO 0 BODY TYPE 0 - NO CARGO BODY TYPE / NOT APPLICABLE - BUS / VAN ( 9-5 SEATS, INC DRIVER ) - BUS ( 6 + SEATS, INC DRIVER ) - VEHICLE TOWING ANOTHER VEHICLE - LOGGING - INTERMODAL CONTAINER CHASSIS 07 - CARGO VAN / ENCLOSED BO 08 - GRAIN, CHIPS, GRAVEL UNIT TYPE PASSENGER VEHICLES ( LESS THAN 9 PASSENGERS ) 0 - SUB - COMPACT - COMPACT - MID SIZE OR HIT / SKIP - ULL SIZE - MINIVAN - SPORT UTILITY VEHICLE 07 - PICKUP 08 - VAN MOTORIZED BICYCLE - SNOWMOBILE / ATV 2 - OTHER PASSENGER VEHICLE 7 - ARM VEHICLE 8 - ARM EQUIPTMENT 9 - MOTORHOME 20 - G CART 2 - TRAIN 22 - OTHER ( EPLAIN IN NARRATIVE ) 3 - NEGOTIATING A CURVE ACTION - PE 0 - CARGO TANK - LAT BED 2 - DUMP MOST DAMAGED AREA IMPACT AREA 3 - CONCRETE MIER 4 - AUTO TRANSPORTER 5 - GARBAGE / REUSE HAS HM PLACARD TRAICWAY DESCRIPTION 4 - TWO - WAY, NOT DIVIDED 2 - TWO - WAY, NOT DIVIDED, CONTINUOUS LET TURN LANE 3 - TWO - WAY, DIVIDED, UNPROTECTED ( PAINTED OR GRASS > 4 T. ) MEDIAN 4 - TWO - WAY, DIVIDED, POSITIVE MEDIAN BARRIER 5 - ONE - WAY TRAICWAY HIT / SKIP UNIT MED / HEAVY TRUCKS OR COMBO UNITS > 0K LBS 0 - NONE 3 - SINGLE UNIT TRUCK OR VAN 2ALE, 6 TIRES 4 - SINGLE UNIT TRUCK; 3 + ALES 5 - SINGLE UNIT TRUCK / TRAILER 6 - TRUCK / TRACTOR ( BOBTAIL ) 7 - TRACTOR / SEMI - TRAILER 8 - TRACTOR / DOUBLE 9 - TRACTOR / TRIPLES 20 - OTHER MED / HEAVY VEHICLE - CENTER RONT - RIGHT RONT - RIGHT SIDE - RIGHT REAR - REAR CENTER 07 - LET REAR 08 - LET SIDE - LET RONT 0 - TOP AND WINDOWS - UNDERCARRIAGE 2 - LOAD / TRAILER 3 - TOTAL ( ALL AREAS ) 5 - ENTERING OR CROSSING SPECIIED LOCATION 6 - WALKING, RUNNING, JOGGING, PLAYING, CYCLING 7 - WORKING 8 - PUSHING VEHICLE 9 - APPROACHING OR LEAVING VEHICLE 20 - STANDING BUS / VAN / LIMO ( 9 OR MORE INCLUDING DRIVER 2 - BUS / VAN ( 9-5 SEATS, INC DRIVER ) 22 - BUS ( 6 + SEATS, INC DRIVER ) 23 - ANIMAL WITH RIDER 24 - ANIMAL WITH BUGGY, WAGON, SURREY 25 - BICYCLE / PEDACYCLIST 26 - PEDESTRIAN / SKATER 27 - OTHER 3 ACTION - NON - CONTACT 2 - NON - CLISION 3 - STRIKING 4 - STRUCK 5 - STRIKING / STRUCK 2 - OTHER ACTION CONTRIBUTING CIRCUMSTANCES 0 - NONE - AILURE TO YIELD - RAN RED LIGHT - RAN STOP SIGN - ECEEDED SPEED LIMIT - UNSAE SPEED 07 - IMPROPER TURN 08 - LET O CENTER - LOWED TO CLOSELY / ACDA 0 - IMPROPER LANE CHANGE / PASSING / O ROAD - IMPROPER BACKING 2 - IMPROPER START ROM PARKED POSITION 3 - STOPPED OR PARKED ILLEGALLY 4 - OPERATING VEHICLE IN NEGLIGENT MANNER 5 - SWERVING TO AVOID ( DUE TO ETERNAL CONDITIONS ) 6 - WRONG SIDE / WRONG WAY 7 - AILURE TO CONTR 8 - VISION OBSTRUCTION 9 - OPERATING DEECTIVE EQUIPTMENT 20 - LOAD SHITING / ALLING / SPILLING 2 - OTHER IMPROPER ACTION 22 - NONE 23 - IMPROPER CROSSING 24 - DARTING 25 - LYING AND / OR ILLEGALLY IN ROADWAY 26 - AILURE TO YIELD RIGHT O WAY 27 - NOT VISIBLE ( DARK CLOTHING ) 28 - INATTENTIVE 29 - AILURE TO OBEY TRAIC SIGNS / SIGNALS / OICER 30 - WRONG SIDE O THE ROAD 3 - OTHER ACTION VEHICLE DEECTS 0 - TURN SIGNALS - HEAD LAMPS - TAIL LAMPS - BRAKES - STEERING - TIRE BLOWOUT 07 - WORN OR SLICK TIRES 08 - TRAILER EQUIPTMENT DEECTIVE - MOTOR TROUBLE 0 - DISABLED ROM PRIOR ACCIDENT - OTHER DEECTS SEQUENCE O S IRST MOST NON - CLISION S 0 - OVERTURN / RLOVER - IRE / EPLOSION - IMMERSION - JACKNIE - CARGO / EQUIPTMENT LOSS OR SHIT - EQUIPTMENT AILURE ( BLOWN TIRE, BRAKE AILURE, ECT ) 07 - SEPERATION O UNITS 08 - RAN O ROAD RIGHT - RAN O ROAD LET 0 - CROSS MEDIAN - CROSS CENTER LINE OPPOSITE DIRECTION O TRAVEL 2 - DOWNHILL RUNAWAY 3 - OTHER NON - CLISION CLISION WITH PERSON, VEHICLE OR OBJECT NOT IED 4 - PEDESTRIAN 2 - PARKED MOTOR VEHICLE 5 - PEDALCYCLE 22 - WORK ZONE MAINTENANCE EQUIPTMENT 6 - RAILWAY VEHICLE ( TRAIN, ENGINE ) 23 - STRUCK BY ALLING, SHITING CARGO 7 - ANIMAL - ARM OR ANYTHING SET IN MOTION BY A MOTOR VEHICLE 8 - ANIMAL - DEER 2 MOVABLE OBJECT 9 - ANIMAL - OTHER 20 - MOTOR VEHICLE IN TRANSPORT CLISION WITH IED OBJECT 25 - IMPACT ATTENUATOR / CRASH CUSHION 26 - BRIDGE OVERHEAD STRUCTURE 27 - BRIDGE PIER OR ABUTMENT 28 - BRIDGE PARAPET 29 - BRIDGE RAIL 30 - GUARDRAIL ACE 3 - GUARDRAIL END 32 - PORTABLE BARRIER 33 - MEDIAN CABLE BARRIER 34 - MEDIAN GUARDRAIL BARRIER 35 - MEDIAN CONCRETE BARRIER 36 - MEDIAN OTHER BARRIER 37 - TRAIC SIGN POST 38 - OVERHEAD SIGN POST 39 - LIGHT / LUMINARIES SUPPORT 40 - UTILITY PE POST, PE OR SUPPORT 42 - CULVERT 43 - CURB 44 - DITCH 45 - EMBANKMENT 46 - ENCE 47 - MAILBO 48 - TREE 49 - IRE HYDRANT 50 - WORK ZONE MAINTENANCE EQUIPTMENT 5 - WALL, BUILDING, TUNNEL 52 - OTHER IED OBJECT UNIT SPEED POSTED SPEED STATED ESTIMATED TRAIC CONTR 0 - NO CONTRS 07 - RAILROAD CROSSBUCKS - STOP SIGN 08 - RAILROAD LASHERS - YIELD SIGN - RAILROAD GATES - TRAIC SIGNAL 0 - CONSTRUCTION BARRICADE - TRAIC LASHERS - PERSON ( LAGGER, OICER ) - SCHO ZONE 2 - PAVEMENT MARKINGS 3 - CROSSWALK LINES 4 - WALK / DON'T WALK 5 - OTHER 6 - NOT REPORTED UNIT DIRECTION 2 3 ROM TO 4 - NORTH 2 - SOUTH 3 - EAST 4 - WEST 5 - NORTHEAST 6 - NORTHWEST 7 - SOUTHEAST 8 - SOUTHWEST Page: 4 of 7 HSY83 OHU ( REV 0/2 )

5 / / OCCUPANT DESJARDIN JAEGAR J US HIGHWAY 23 GIBSONBURG Ohio Home: COMPLAINT 0 NO M / C UA428 OENSE CHARGED ( LOCAL CODE ) OENSE DESCRIPTION CITATION NUMBER HANDS - REE USED HARDER THERESA LYNN 30 OH HERTORD CT MAUMEE Ohio INJURIES INJURED TAKEN BY EMS AGENCY MEDICAL ACILITY INJURED TAKEN TO EQUIPTMENT USED COMPLAINT NO M / C RY9325 OENCE CHARGED ( LOCAL CODE ) OENSE DESCRIPTION CITATION NUMBER HANDS - REE USED 4 OH INJURIES INJURED TAKEN BY EQUIPTMENT USED EQUIPTMENT - NO INJURY / NONE REPORTED - NOT TRANSPORTED / TREATED AT SCENE 2 - POSSIBLE 2 - EMS 3 - NON - INCAPACITATING 0 - NONE USED - VEHICLE OCCUPANT - NONE USED 2 - RELECTIVE CLOTHING 3 - PICE - CHILD RESTRAINT SYSTEM - OREWARD ACING 4 - INCAPACITATING - SHOULDER BELT ONLY USED 0 - USED 3 - LIGHTING - CHILD RESTRAINT SYSTEM - REAR ACING 5 - ATAL - PROTECTIVE PADS USED - LAP BELT ONLY USED 07 - BOOSTER SEAT ( ELBOWS, KNEES, ECT ) - SHOULDER AND LAP BELT USED 08 - USED M Home: SEATING POSITION 0 - RONT - LET SIDE ( DRIVER ) - RONT - MIDDLE - RONT - RIGHT SIDE - SECOND - LET SIDE ( PASSENGER ) - SECOND - MIDDLE - SECOND - RIGHT SIDE EJECTION - NOT EJECTED - NOT 2 - TOTALLY EJECTED 2 - ETRICATED BY MECHANICAL MEANS 3 - PARTIALLY EJECTED 3 - ETRICATED BY 4 - NOT APPLICABLE NON - MECHANICAL MEANS 07 - THIRD - LET SIDE ( SIDE CAR ) 2 - PASSENGER IN UNENCLOSED CARGO AREA 08 - THIRD - MIDDLE 3 - TRAILING UNIT 4 - RIDING ON VEHICLE ETERIOR ( NON - TRAILING UNIT ) - THIRD - RIGHT SIDE SLEEPER SECTION O CAB ( TRUCK ) 6 - OTHER - PASSENGER IN OTHER ENCLOSED CARGO AREA ( NON - TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP ) OPERATOR LICENSE CLASS CONDITION 5 - ELL ASLEEP, AINTED, ATIGUED - CLASS A - APPARENTLY NORMAL 6 - UNDER THE INLUENCE O 2 - CLASS B 2 - PHYSICAL IMPAIRMENT MEDICATIONS, DRUGS, ALCOH 3 - CLASS C 3 - EMOTIONAL ( DEPRESSED, ANGRY, DISTURBED ) 7 - OTHER 4 - REGULAR CLASS ( OHIO IS "D" ) 4 - ILLNESS 5 - MC / MOPED ONLY AIR BAG USAGE - NOT DEPLOYED 2 - DEPLOYED RONT 3 - DEPLOYED SIDE 4 - DEPLOYED BOTH RONT / SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN ALCOH / DRUGS SUSPECTED - NONE 2 - YES - ALCOH SUSPECTED 3 - YES - HBD NOT IMPAIRED 4 - YES - DRUGS SUSPECTED 5 - YES - ALCOH AND DRUGS SUSPECTED ALCOH TEST STATUS ALCOH TEST TYPE DRUG TEST STATUS DRUG TEST TYPE - NONE GIVEN 2 - TEST REUSED - NONE 4 - BREATH 5 - OTHER - NONE GIVEN 2 - TEST REUSED - NONE - NO DISTRACTION REPORTED 2 - PHONE 3 - TETING / ING 4 - ELECTRONIC COMMUNICATION 5 - OTHER ELECTRONIC ( NAVIGATION, RADIO, DVD ) 6 - OTHER INSIDE VEHICLE 7 - ETERNAL DISTRACTION Home: COMPLIANT Home: HSY83 OHM ( REV 0/2 ) Page: 5 of 7

6 / / OCCUPANT PERRY ALLISON JEAN LIBBEY RD PERRYSBURG Ohio Home: COMPLAINT 0 NO M / C TW878 OENSE CHARGED ( LOCAL CODE ) OENSE DESCRIPTION CITATION NUMBER ACDA - Assured Clear Distance Ahead HANDS - REE 45.2A USED OH 4 COMPLAINT Home: NO M / C OENCE CHARGED ( LOCAL CODE ) OENSE DESCRIPTION CITATION NUMBER HANDS - REE USED INJURIES - NO INJURY / NONE REPORTED 2 - POSSIBLE 3 - NON - INCAPACITATING 4 - INCAPACITATING 5 - ATAL INJURED TAKEN BY - NOT TRANSPORTED / TREATED AT SCENE 2 - EMS 3 - PICE EQUIPTMENT USED 0 - NONE USED - VEHICLE OCCUPANT - SHOULDER BELT ONLY USED - LAP BELT ONLY USED - SHOULDER AND LAP BELT USED EQUIPTMENT - CHILD RESTRAINT SYSTEM - OREWARD ACING - CHILD RESTRAINT SYSTEM - REAR ACING 07 - BOOSTER SEAT 08 - USED - NONE USED 0 - USED - PROTECTIVE PADS USED ( ELBOWS, KNEES, ECT ) 2 - RELECTIVE CLOTHING 3 - LIGHTING SEATING POSITION 0 - RONT - LET SIDE ( DRIVER ) - RONT - MIDDLE - RONT - RIGHT SIDE - SECOND - LET SIDE ( PASSENGER ) - SECOND - MIDDLE - SECOND - RIGHT SIDE EJECTION - NOT EJECTED - NOT 2 - TOTALLY EJECTED 2 - ETRICATED BY MECHANICAL MEANS 3 - PARTIALLY EJECTED 3 - ETRICATED BY 4 - NOT APPLICABLE NON - MECHANICAL MEANS 07 - THIRD - LET SIDE ( SIDE CAR ) 2 - PASSENGER IN UNENCLOSED CARGO AREA 08 - THIRD - MIDDLE 3 - TRAILING UNIT 4 - RIDING ON VEHICLE ETERIOR ( NON - TRAILING UNIT ) - THIRD - RIGHT SIDE SLEEPER SECTION O CAB ( TRUCK ) 6 - OTHER - PASSENGER IN OTHER ENCLOSED CARGO AREA ( NON - TRAILING UNIT SUCH AS A BUS, PICK-UP WITH CAP ) OPERATOR LICENSE CLASS CONDITION 5 - ELL ASLEEP, AINTED, ATIGUED - CLASS A - APPARENTLY NORMAL 6 - UNDER THE INLUENCE O 2 - CLASS B 2 - PHYSICAL IMPAIRMENT MEDICATIONS, DRUGS, ALCOH 3 - CLASS C 3 - EMOTIONAL ( DEPRESSED, ANGRY, DISTURBED ) 7 - OTHER 4 - REGULAR CLASS ( OHIO IS "D" ) 4 - ILLNESS 5 - MC / MOPED ONLY AIR BAG USAGE - NOT DEPLOYED 2 - DEPLOYED RONT 3 - DEPLOYED SIDE 4 - DEPLOYED BOTH RONT / SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN ALCOH / DRUGS SUSPECTED - NONE 2 - YES - ALCOH SUSPECTED 3 - YES - HBD NOT IMPAIRED 4 - YES - DRUGS SUSPECTED 5 - YES - ALCOH AND DRUGS SUSPECTED ALCOH TEST STATUS - NONE GIVEN 2 - TEST REUSED ALCOH TEST TYPE - NONE 4 - BREATH 5 - OTHER DRUG TEST STATUS - NONE GIVEN 2 - TEST REUSED DRUG TEST TYPE - NONE - NO DISTRACTION REPORTED 2 - PHONE 3 - TETING / ING 4 - ELECTRONIC COMMUNICATION 5 - OTHER ELECTRONIC ( NAVIGATION, RADIO, DVD ) 6 - OTHER INSIDE VEHICLE 7 - ETERNAL DISTRACTION REED BRIANNA LYNNE SWARTZWALDER RD MILLBURY Ohio COMPLIANT BRIGGS MAKENZIE G LEMOYNE RD WALBRIDGE Ohio COMPLIANT HSY83 OHM ( REV 0/2 ) Home: Home: Page: 6 of 7

7 OCCUPANT / WITNESS ADDENDUM AIKMAN ANGELICA MAE SOUTH POINTE RD MILLBURY Ohio WALBRIDGE Ohio WALSH KENNEDY JANE INJURIES INJURED TAKEN BY EMS AGENCY MEDICAL ACILITY INJURED TAKEN TO EQUIPTMENT USED BLUE GRASS DR WALBRIDGE Ohio MILLBURY Ohio SEATING POSITION AIR BAG USAGE EJECTION 5 CONTACT PHONE- INCLUDE AREA CODE - EMALE INJURIES - NO INJURY / NONE REPORTED INJURED TAKEN BY - NOT TRANSPORTED / EQUIPTMENT USED EQUIPTMENT 2 - POSSIBLE 3 - NON - INCAPACITATING 4 - INCAPACITATING 5 - ATAL TREATED AT SCENE 2 - EMS 3 - PICE 0 - NONE USED - VEHICLE OCCUPANT - SHOULDER BELT ONLY USED - LAP BELT ONLY USED - SHOULDER AND LAP BELT USED - CHILD RESTRAINT SYSTEM OREWARD - ACING - CHILD RESTRAINT SYSTEM REAR - ACING 07 - BOOSTER SEAT 08 - USED - NONE USED 0 - USED - PROTECTIVE PADS USED ( ELBOWS, KNEES, ECT ) 2 - RELECTIVE CLOTHING 3 - LIGHTING SEATING POSITION - PASSENGER IN OTHER ENCLOSED CARGO AREA AIR BAG USAGE EJECTION 0 - RONT - LET SIDE ( DRIVER ) - RONT - MIDDLE - RONT - RIGHT SIDE - SECOND - LET SIDE ( PASSENGER ) - SECOND MIDDLE - SECOND - RIGHT SIDE 07 - THIRD - LET SIDE ( SIDE CAR ) 08 - THIRD MIDDLE ( NON - TRAILING UNIT SUCH AS BUS, PICK-UP WITH CAB ) 2 - PASSENGER IN UNENCLOSED CARGO AREA 3 - TRAILING UNIT 4 - RIDING ON VEHICLE ETERIOR ( NON - TRAILING UNIT ) OTHER - NOT DEPLOYED 2 - DEPLOYED RONT 3 - DEPLOYED SIDE 4 - DEPLOYED BOTH RONT / SIDE 5 - NOT APPLICABLE 9 - DEPLOYMENT UNKNOWN - NOT EJECTED 2 - TOTALLY EJECTED 3 - PARTIALLY EJECTED 4 - NOT APPLICABLE - NOT 2 - ETRACTED BY MECHANICAL MEANS 3 - ETRACTED BY NON - MECHANICAL MEANS - THIRD - RIGHT SIDE 0 - SLEEPER SECTION O CAB ( TRUCK ) Page: 7 of 7 HSY8355 OHP ( REV 0/2 )