Page 1 of 4 Pages New York State Department of Motor Vehicles

Precinct POLICE ACCIDENT REPORT (NYC) 19

105 MV-104AN (7/11) -
Accident No. Complaint
MV-2019-105-000100 Number ! AMENDED REPORT
1
Accident Date Day of Week MilitaryTime No. of No. Injured No. Killed Not Investigated at Scene Left Scene Police Photos 20
- Month Day Year Vehicles -
Reconstructed Yes ✔ No
1 6 2019 SUNDAY 01:13 2 1 0
VEHICLE 1 ✔ VEHICLE 2 BICYCLIST PEDESTRIAN OTHER PEDESTRIAN
VEHICLE 1 - Driver State of Lic. VEHICLE 2- Driver State of Lic.
2 License ID Number 259277563 NY License ID Number 411711234 NY 21
- Driver Name -exactly Driver Name - exactly 20
as printed on license EVANS, MAURICE, E as printed on license LEMORIN, MICHAEL
Address (Include Number & Street) Apt. No. Address (Include Number & Street) Apt. No.
3 DAMSON LN 40 MEMORIAL HWY 22-I
City or Town State Zip Code City or Town State Zip Code 22
VALLEY STREAM NY 11581 NEW ROCHELLE NY 10801 7
3 Date of Birth Sex Unlicensed No. of Public Date of Birth Sex Unlicensed No. of Public
Month Day Year Occupants Property Month Day Year Occupants Property
1 4 2 1980 M 2 Damaged 5 21 1954 M 1 Damaged
Name–exactly as printed on registration Sex Date of Birth Name–exactly as printed on registration Sex Date of Birth
Month Day Year Month Day Year
EVANS, MAURICE, E M 4 2 1980 LEMORIN, MICHAEL M 5 21 1954
Address (Include Number & Street) Apt. No. Haz. Released Address (Include Number & Street) Apt. No. Haz. Released 23
4 Mat Mat. 3
3 DAMSON LN .Code 30 CLINTON PL 3D Code
4 City or Town State Zip Code City or Town State Zip Code
VALLEY STREAM NY 11581 NEW ROCHELLE NY 10801 24
Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code
3
5
HLD2510 NY 2004 LEXUS SEDAN 693 GHH2425 NY 2015 SW/SUV 11
Ticket/Arrest Ticket/Arrest
1 Number(s) Number(s)
Violation Violation
Section(s) Section(s)
25
Check if involved vehicle is: Check if involved vehicle is: Circle the diagram below that describes the accident, or draw your own 1
6 ! more than 95 inches wide; ! more than 95 inches wide; diagram in space #9. Number the vehicles.
1 V ! more than 34 feet long; V ! more than 34 feet long; Rear End Left Turn Right Angle Right Turn Head On
E ! operated with an overweight permit; E ! operated with an overweight permit;
H ! operated with an overdimension permit. H ! operated with an overdimension permit. 1. 3. 5. 7.
I VEHICLE 1 DAMAGE CODES I VEHICLE 2 DAMAGE CODES Sideswipe Left Turn Right Turn Sideswipe 26
C Box 1 - Point of Impact 1 2 C Box 1 - Point of Impact 1 2 (same direction) (opposite 12
7
L Box 2 - Most Damage 12 12 L Box 2 - Most Damage 3 3 2. 0. 4. 6. 8.
1 E Enter up to three E Enter up to three ACCIDENT DIAGRAM
3 4 5 3 4 5
more Damage Codes 11 10 18 more Damage Codes 18 18 18
1 2 27
Vehicle By Vehicle By RICHMOND TOWING INC 718-323-2576 1
Towed: Towed:
To To 106-16 148 STREET, JAMAICA NY 11435

DIAGRAM ATTACHED ON SUBSEQUENT PAGE

VEHICLE DAMAGE CODING:
1-13. SEE DIAGRAM ON RIGHT. 2 SIDE SWIPE (SAME DIR)
14. UNDERCARRIAGE 17. DEMOLISHED
15. TRAILER 18. NO DAMAGE 9. 28
16. OVERTURNED 19. OTHER Cost of repairs to any one vehicle will be more than $1000. 1
Unknown/Unable to Determine ✔ Yes No
Reference Marker Coordinates (if available) NEW YORK QUEENS
Place Where Accident Occurred: BRONX KINGS ✔ RICHMOND
Latitude/Northing: HILLSIDE AVENUE
Road on which accident occurred___________________________________________________________________________
40.724693 (Route Number or Street Name) 29
____________________
-
212 STREET
at 1) intersecting street ___________________________________________________________________________________
Longitude/Easting: (Route Number or Street Name)
N S
or 2) _____ ______ E W of _______________________________________________________________________________
-73.7541
_____________________ Feet Miles (Milepost, Nearest Intersecting Route Number or Street Name)
Accident Description/Officer’s Notes
DRIVER OF VEHICLE NUMBER ONE STATES HE WAS PROCEEDING STRAIGHT IN THE 30

RIGHT LANE WHEN VEHICLE NUMBER TWO, IN THE LEFT LANE, COMMENCED A LANE CHANGE INTO THE -
USE
RIGHT LANE AND COLLIDED INTO THE DRIVER SIDE OF VEHICLE NUMBER ONE. PASSENGER OF VEHICLE COVER
SHEET

P
NUMBER ONE COMPLAINED OF PAIN TO COLLARBONE AND NECK RESULTING FROM THE COLLISION.
PASSENGER OF VEHICLE NUMBER ONE WAS TAKEN TO NORTH SHORE MANHASSET HOSPITAL (ACR# 33524).
8 9 10 11 12 13 14 15 16 17 BY TO 18 Names of all involved Date of Death Only
A A 1 1 4 1 38 M - - - - - EVANS, MAURICE, E
L
L B 1 3 4 1 29 M 4 12 6 14552EV 2901 YOUNG, CHRISTOPHER, G
I C 2 1 4 1 64 M - - - - - LEMORIN, MICHAEL
N
V
O
L
V
E
D
Officer’s Rank Tax ID No. NCIC No. Precinct Post/Sector Reviewing Date/Time Reviewed
and Officer
Signature ➧ POM
942372 03030 105 SGT KRISHNA D 01/06/2019 08:54
Print Name
in Full PHILIP POLITIS TANDRIAN
PERSONS KILLED OR INJURED IN ACCIDENT (Letter designation of persons killed or injured must correspond with letter designation on front).
B Last Name First M.I. Last Name First M.I.
YOUNG CHRISTOPHER G
Address Address
227-46 109 AVENUE PH QUEENS NY
Date of Birth Telephone (Area Code) Date of Birth Telephone (Area Code)
Month Day Year Month Day Year
6 21 1989 ( ) 6313329842 ( )
Last Name First M.I. Last Name First M.I.

Address Address

Date of Birth Telephone (Area Code) Date of Birth Telephone (Area Code)
Month Day Year Month Day Year
( ) ( )
Last Name First M.I.
Highway Dist. at Scene? Yes ✔ No
Name:
Address

Date of Birth Telephone (Area Code) Shield No.

Month Day Year
( )

ENTER INSURANCE POLICY NUMBER FROM INSURANCE IDENTIFICATION CARD, EXPIRATION DATE (IN ALL CASES), AND VIN.
Vehicle No. 1 ____________________________________________
913876698 Vehicle No. 2_____________________________________________
103119949
Expiration Date ___________________________
03/07/2019 Expiration Date ___________________________
04/17/2019
VIN ___________________________________________________
JTHBD192940083777 VIN ___________________________________________________
WBAVL1C52FVY29607

WITNESS (Attach separate sheet, if necessary)

Name Address Phone

DUPLICATE COPY REQUIRED FOR:

! Dept. of Motor Vehicles ! Motor Transport Division ! NYC Taxi & Limousine Comm. ! Other City Agency
(if anyone is killed/injured) (P.D. vehicle involved) (if a Licensed taxi or limousine (Specify)
involved)
! Office of Comptroller ! Personnel Safety Unit ! Highway Unit _____________ _____________________
(if a City vehicle involved) (if a P.D. vehicle involved)
NOTIFICATIONS: (Enter name, address, and relationship of friend or relative notified. If aided person is unidentified, list Missing Person Squad member who
was notified. In either case, give date and time of notification.)
______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

PROPERTY DAMAGED (other than vehicles) OWNER OF PROPERTY (include city agency, where applicable)

IF NYPD VEHICLE IS INVOLVED:

Police Vehicle –Operator’s First Name Last Name Rank Shield No. Tax ID. No. Command

Make of Vehicle Year Type of Vehicle Plate No. Dept. Vehicle No. Assigned To What Command

Equipment in Use At Time of Accident

Siren Horn Turret Light 4-Way Flasher High-Level Warning Lights Traffic Cones Headlights

ACTIONS OF POLICE VEHICLE

Responding to Code Signal Complying with Station House Directive

Pursuing Violator Routine Patrol

Other (Describe)

MV-104AN (7/11) Page 2 of 4 Pages

 Page 3 of 4 Pages New York State Department of Motor Vehicles
Precinct POLICE ACCIDENT REPORT (NYC) 19
105 MV-104AN (7/11) -
Accident No. Complaint
MV-2019-105-000100 Number ! AMENDED REPORT
1
Accident Date Day of Week MilitaryTime No. of No. Injured No. Killed Not Investigated at Scene Left Scene Police Photos 20
- Month Day Year Vehicles -
Reconstructed Yes ✔ No
1 6 2019 SUNDAY 01:13 2 1 0
VEHICLE VEHICLE BICYCLIST PEDESTRIAN OTHER PEDESTRIAN
VEHICLE - Driver State of Lic. VEHICLE - Driver State of Lic.
2 License ID Number License ID Number 21
- Driver Name -exactly Driver Name - exactly -
as printed on license as printed on license
Address (Include Number & Street) Apt. No. Address (Include Number & Street) Apt. No.

City or Town State Zip Code City or Town State Zip Code 22
-
3 Date of Birth Sex Unlicensed No. of Public Date of Birth Sex Unlicensed No. of Public
Month Day Year Occupants Property Month Day Year Occupants Property
1 Damaged Damaged
Name–exactly as printed on registration Sex Date of Birth Name–exactly as printed on registration Sex Date of Birth
Month Day Year Month Day Year

Address (Include Number & Street) Apt. No. Haz. Released Address (Include Number & Street) Apt. No. Haz. Released 23
4 Mat Mat. -
.Code Code
4 City or Town State Zip Code City or Town State Zip Code

24
Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code
-
5
Ticket/Arrest Ticket/Arrest
1 Number(s) Number(s)
Violation Violation
Section(s) Section(s)
25
Check if involved vehicle is: Check if involved vehicle is: Circle the diagram below that describes the accident, or draw your own -
6 ! more than 95 inches wide; ! more than 95 inches wide; diagram in space #9. Number the vehicles.
1 V ! more than 34 feet long; V ! more than 34 feet long; Rear End Left Turn Right Angle Right Turn Head On
E ! operated with an overweight permit; E ! operated with an overweight permit;
H ! operated with an overdimension permit. H ! operated with an overdimension permit. 1. 3. 5. 7.
I VEHICLE 1 DAMAGE CODES I VEHICLE 2 DAMAGE CODES Sideswipe Left Turn Right Turn Sideswipe 26
C Box 1 - Point of Impact 1 2 C Box 1 - Point of Impact 1 2 (same direction) (opposite -
7
L Box 2 - Most Damage L Box 2 - Most Damage 2. 0. 4. 6. 8.
1 E Enter up to three E Enter up to three ACCIDENT DIAGRAM
3 4 5 3 4 5
more Damage Codes more Damage Codes
1 2 27
Vehicle By Vehicle By 1
Towed: Towed:
To To
DIAGRAM ATTACHED ON SUBSEQUENT PAGE
VEHICLE DAMAGE CODING:
1-13. SEE DIAGRAM ON RIGHT. 2 SIDE SWIPE (SAME DIR)
14. UNDERCARRIAGE 17. DEMOLISHED
15. TRAILER 18. NO DAMAGE 9. 28
16. OVERTURNED 19. OTHER Cost of repairs to any one vehicle will be more than $1000. 1
Unknown/Unable to Determine Yes No
Reference Marker Coordinates (if available) NEW YORK QUEENS
Place Where Accident Occurred: BRONX KINGS ✔ RICHMOND
Latitude/Northing: HILLSIDE AVENUE
Road on which accident occurred___________________________________________________________________________
40.724693 (Route Number or Street Name) 29
____________________
-
212 STREET
at 1) intersecting street ___________________________________________________________________________________
Longitude/Easting: (Route Number or Street Name)
N S
or 2) _____ ______ E W of _______________________________________________________________________________
-73.7541
_____________________ Feet Miles (Milepost, Nearest Intersecting Route Number or Street Name)
Accident Description/Officer’s Notes
DRIVER OF VEHICLE NUMBER TWO STATES HE WAS IN THE LEFT LANE AND WANTED 30
TO PULL OFF INTO THE GAS STATION LOCATED AT THE RIGHT SIDE OF THE STREET. DRIVER NUMBER -
USE
TWO FURTHER STATES HE IMMEDIATELY SWERVED TO THE RIGHT AND INADVERTENTLY COLLIDED INTO COVER
SHEET

P
VEHICLE NUMBER ONE, WHICH HE DID NOT REALIZE WAS THERE. DRIVER NUMBER TWO CLAIMED NO
INJURIES. 105 PCT PATROL SUPERVISOR SGT TOTH ON SCENE.
8 9 10 11 12 13 14 15 16 17 BY TO 18 Names of all involved Date of Death Only
A
L
L
I
N
V
O
L
V
E
D
Officer’s Rank Tax ID No. NCIC No. Precinct Post/Sector Reviewing Date/Time Reviewed
and Officer
Signature ➧ POM
942372 03030 105 SGT KRISHNA D 01/06/2019 08:54
Print Name
in Full PHILIP POLITIS TANDRIAN
PERSONS KILLED OR INJURED IN ACCIDENT (Letter designation of persons killed or injured must correspond with letter designation on front).
Last Name First M.I. Last Name First M.I.

Address Address

Date of Birth Telephone (Area Code) Date of Birth Telephone (Area Code)
Month Day Year Month Day Year
( ) ( )
Last Name First M.I. Last Name First M.I.

Address Address

Date of Birth Telephone (Area Code) Date of Birth Telephone (Area Code)
Month Day Year Month Day Year
( ) ( )
Last Name First M.I.
Highway Dist. at Scene? Yes No
Name:
Address

Date of Birth Telephone (Area Code) Shield No.

Month Day Year
( )

ENTER INSURANCE POLICY NUMBER FROM INSURANCE IDENTIFICATION CARD, EXPIRATION DATE (IN ALL CASES), AND VIN.
Vehicle No. ____________________________________________ Vehicle No. _____________________________________________

Expiration Date ___________________________ Expiration Date ___________________________

VIN ___________________________________________________ VIN ___________________________________________________

WITNESS (Attach separate sheet, if necessary)

Name Address Phone

DUPLICATE COPY REQUIRED FOR:

! Dept. of Motor Vehicles ! Motor Transport Division ! NYC Taxi & Limousine Comm. ! Other City Agency
(if anyone is killed/injured) (P.D. vehicle involved) (if a Licensed taxi or limousine (Specify)
involved)
! Office of Comptroller ! Personnel Safety Unit ! Highway Unit _____________ _____________________
(if a City vehicle involved) (if a P.D. vehicle involved)
NOTIFICATIONS: (Enter name, address, and relationship of friend or relative notified. If aided person is unidentified, list Missing Person Squad member who
was notified. In either case, give date and time of notification.)
______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

PROPERTY DAMAGED (other than vehicles) OWNER OF PROPERTY (include city agency, where applicable)

IF NYPD VEHICLE IS INVOLVED:

Police Vehicle –Operator’s First Name Last Name Rank Shield No. Tax ID. No. Command

Make of Vehicle Year Type of Vehicle Plate No. Dept. Vehicle No. Assigned To What Command

Equipment in Use At Time of Accident

Siren Horn Turret Light 4-Way Flasher High-Level Warning Lights Traffic Cones Headlights

ACTIONS OF POLICE VEHICLE

Responding to Code Signal Complying with Station House Directive

Pursuing Violator Routine Patrol

Other (Describe)

MV-104AN (7/11) Page 4 of 4 Pages

Side Swipe (same dir) : MV-2019-105-000100
Reporting Officer : POM PHILIP POLITIS
Reviewing Officer : SGT KRISHNA D TANDRIAN Reviewed Date : 01/06/2019 08:54