WA-89302_95746_CA_RPTS_20200215

This report has been redacted to prevent the disclosure of personally identifiable information.
DMV-349 (Rev. 1/09)THIS REPORT IS FOR THE USE OF THE DIVISION OF MOTOR VEHICLES. THE DATA IS
COLLECTED FOR STATISTICAL ANALYSIS AND SUBSEQUENT HIGHWAY SAFETY PROGRAMMING. DETERMINATIONS OF "FAULT" ARE THE RESPONSIBILITY OF INSURERS OR
OF THE STATE'S COURTS.
Do not write in these spaces
Date Received by DMVDate
02/15/2020
9
8
No. of Units Involved Form 1 of 1 Supplemental Report Non-Reportable
County
HERTFORD
Time
09:10
Local Use/Patrol Area
200215022AA - 06 10
30
11
30
1
1
2
2
3
1
4
1
5
6
2
7
1
13
14
19
15
16
17
6
18
19
12
0
33 Relation to
Roadway Surface
L
O
C
A
T
I
O
N
1 Crash
Occurred X
In AHOSKIE or 01.40 Miles
X
N S E W
Municipality
on NC 11
Use Highway Number, Street Name or Adjacent County or State Line
Highway Number, or Highway, Street. (If ramp or service road, indicate on line)Ramp or
Service Road
(R.R. Crossing #Miles 0
outside municipality
N S E W
NC 461XAt
From
X
N S E W
toward Use Highway Number, Street Name or Adjacent County or State Line
SR 1408 Latitude
UNIT #1 VEHICLE PEDESTRIAN HIT & RUN X COMMERCIAL
VEHICLE
Driver DONALD
First
FITZGERALD
Middle
BLAKE
Last
Address 108 LIVERMAN MILL RD
City State ZipAHOSKIENC 27910-8102
Same Address on Driver's
License?X Yes No
Driver's
PhoneNumbers
[phone]H
W
D.L.#REDACTED State NC
CDL License X
DOB REDACTED 34 Vision
Obstruction 0 1 135 Physical
Condition
36 D.L.
Restrictions
37 Alcohol/
Drugs Suspected 0 38 Alcohol/
Drugs Test 0 039 Results
(if known)
40 Vehicle
Seizure (DWI)
UNIT #2 X VEHICLE PEDESTRIAN HIT & RUN
Driver COREY
First
ALAN
Middle
HARRINGTON
Last
Address 151 BENTHALL BRIDGE RD
City State ZipMURFREESBORONC 27855-9669
Same Address on Driver's
License?X Yes No
Driver's
PhoneNumbers
[phone]H
W
D.L.#REDACTED State NC
CDL License
DOB REDACTED 34 Vision
Obstruction 0 1 035 Physical
Condition
36 D.L.
Restrictions
37 Alcohol/
Drugs Suspected 0 38 Alcohol/
Drugs Test 0 039 Results
(if known)
40 Vehicle
Seizure (DWI)
OTHER
27910ZipNCStateAHOSKIECity
1339 US HWY 13 SAddress
Same as Driver?
WT JERNIGAN AND SON TRUCKINGOwner
Same Address as Driver?
2020Plate
YearNCPlate
StateNH5180Plate #
4V4KC9EH6LN268470VIN
5E86989Policy #
EMC PROPERTY & CASUALTY
RBQ-743 TAD
Vehicle
Make VOLVO Vehicle
Year 2020 1441 Vehicle
Style (Type)
42 Vehicle
Drivable X
Yes
No
Insurance
Company
44 Estimated
Damage $90,000.00
27855-9669ZipNCStateMURFREESBOROCity
151 BENTHALL BRIDGE RDAddress
Same as Driver?
COREY ALAN HARRINGTONOwner
Same Address as Driver?
2020Plate
YearNCPlate
StateFCT4061Plate #
1FADP3FEXJL221175VIN
402348733 001Policy #
STATE FARM
FD-743 TAD
Vehicle
Make FORD Vehicle
Year 2018 141 Vehicle
Style (Type)
42 Vehicle
Drivable X
Insurance
Company
44 Estimated
Damage $10,000.00
Yes
No
X
20 COMMERCIAL VEHICLE: Cargo, Carrier Name, Address, Source
45 Cargo Body Type 3 Same Address as owner?
WT JERNIGAN AND SON TRUCKING
1339 US HWY 13 S
AHOSKIE, NC 27910
TruckX
Source:
Shippin
g
Driver
Carrier Identification Numbers, GVWR, Axles
US DOT#311448 ICC#Axles on Vehicle
Including Trailers 5
State State #IFTA#
FEI#Fleet #Gross Vehicular
Weight Rating
NC 3547064
562110946 1 117000
21 22 23 25 26 27 28 29 30 31 3224
A
B
1 1 1 Unit 1-Drv 1, Ped 1, etc. see above B M 2 0 0 2 1 5
C
D
E
F
G
H
2 1 1 Unit 2-Drv 2, Ped 2, etc. see above W M 2 2 0 2 1 3
see above
see above
Veh# 1 Towed To/By: BRITTS TOWING / BRITTS TOWING
Veh# 2 Towed To/By: FREEMANS TOWING / FREEMANS TOWING
46 Name of EMS A - HERTFORD COUNTY EMS
47 Injured Taken
by EMS to A - REFUSED TRANSPORT
46 Name of EMS B - HERTFORD COUNTY EMS
47 Injured Taken
by EMS to B - VIDANT RCH, AHOSKIE
(Treatment Facility and City or Town)(Treatment Facility and City or Town)
ft.
Near
Unit
Longitude
Altitude
20
1
AD.L.
Class CD.L.Class
2
This report has been redacted to prevent the disclosure of personally identifiable information.
48 POINTS OF INTIAL
CONTACT(Write in Codes)
Unit #
Unit #
1 39
2 1,2,3
VEHICLE INFO
60 Authorized Speed Limit
Veh #1 Veh #2 ROADWAY INFO
69 Road Feature
WORK ZONE RELATED
78 Work Zone Area 57
Local Use/Patrol Area:200215022AA - 06
CRASH SEQUENCE (Unit
Level)
55 55
Unit #1 Unit #2 61 Estimate of Original Traveling Speed 70 Road Character 79 Work Activity
80 Work Area Marked462 Estimate of Speed at Impact 71 Road Classification
81 Crash Location63 Tire Impressions Before Impact (ft.)72 Road Surface Type
49 Vehicle Maneuver/Action
50 Non-Motorist Action
4
51 Non-Motorist Location Prior to Impact
52 Crash Sequence - First Event for this Unit 3030
53 Crash Sequence - Second Event 99
54 Crash Sequence - Third Event
55 Crash Sequence - Fourth Event
56 Most Harmful Event for this Unit 3030
57 Distance/Direction of Object Struck 00
58 Vehicle Underride/Override 33
59 Vehicle Defects 00
6055
5515
00
64 Distance travelled After Impact (ft.)
65 Emergency Vehicle Use
66 Post Crash Fire (if 'Yes' check block)
0134
67 School Bus - Contact Vehicle
68 School Bus - Noncontact Vehicle
X X
1
3
4
73 Road Configuration 2
74 Access Control 1
75 Number of Lanes 2
76 Traffic Control Type 1
77 Traffic Control Oper 1
TRAILER INFO.Unit #1 Unit #2
1182 Trailer Type 0
2
96
48
1st Trailer No. Axles
Width (inches)
Length (feet)
2nd Trailer No. Axles
Width (inches)
Length (feet)
Overwidth Permit #
83 Unit #
Overwidth Trailer
and OverwidthMobilehome
COMMERCIAL VEHICLE: Hazardous Material InvolvementHaz Mat Placard
Hazardous Cargo Released
Carrying Haz Mat
From Placard indicateX
X
X
Yes
Yes
Yes
No
No
No
(Does not include fuel from fuel tank)
4-digit placard number or name from diamond or box
1-digit number from bottom of diamond
VEHICLE 1 WAS TRAVELING WEST ON NC 461. VEHICLE 2 WAS TRAVELING SOUTH ON NC 11. VEHICLE 1 FAILED TO YIELD TO VEHICLE 2 AND
PULLED INTO THE INTERSECTION OF NC 11 AND NC 461. VEHICLE 1 AND VEHICLE 2 COLLIDED IN THE INTERSECTION OF NC 11 AND NC 461. AFTER THE COLLISION, VEHICLE 1 AND VEHICLE 2
CAUGHT ON FIRE.
84 DIAGRAM
Unit # 1 was X Traveling
Parked Facing
X
N S E W
NC 461 Unit # 2 was X Traveling
Parked Facing
X
N S E W
NC 11
ADDITIONAL PROPERTY DAMAGE
86 Type/ Owner Owner Address
Estimated Damage $
WITNESSES
Name
Name
Address Phone No
Phone No.Address
TRAFFIC VIOLATION(S)
DONALD FITZGERALD BLAKE 54020G3 - FAILURE TO YIELD AT STOP SIGNCharge(s) (Citation # optional)
Address
Name
Name
Officer Name
TRP. K R GENAO
Officer Number
2924
Department
NC STATE HIGHWAY PATROL NCNHP0000
Date of Report
02/15/2020
State Property?
Form 1 of 1
(include pertinent unusual aspects which are not listed elsewhere on the form)
1Unit
Indicate
North
85 NARRATIVE
onon