8

THIS REPORT IS FOR THE USE OF THE DIVISION OF MOTOR VEHICLES. THE DATA IS COLLECTED FOR
0
DMV-349 (Rev. 1/2009) STATISTICAL ANALYSIS AND SUBSEQUENT HIGHWAY SAFETY PROGRAMMING. DETERMINATIONS OF Do not write in these spaces
"FAULT" ARE THE RESPONSIBILITY OF INSURERS OR OF THE STATE'S COURTS.
2 9

1 No. of Units Involved Form 1 of 4 Supplemental Report Non-Reportable 2019001537 Date Received by DMV
Crash Date County Time Local Use/Patrol Area
3
01/15/2019 NEW HANOVER 17:34 DISTRICT 5
mm/dd/ccyy (24 Hour Clock)
10
2 Crash X In outside municipality
L Roadway Surface 1 occurred Near WILMINGTON 21
33 Relation to
3 O Municipality
or Miles N S E W
X
C on LCL S COLLEGE RD (R.R. Crossing # ) .18 Miles ft. N S E W
(0 ft.-Intersection)
A Highway Number, or Highway, Street. (If ramp or service road, indicate on line)
Ramp or
3 T Service Road (If available)
11
1 O at or from LCL NEW CENTRE DR
I
X toward LCL UNIVERSITY DR Latitude

N
Use Highway Number, Street Name or Adjacent County or State Line N S E W Use Highway Number, Street Name or Adjacent County or State Line Longitude
21
Altitude

UNIT # 1 X VEHICLE PEDESTRIAN HIT & RUN COMMERCIAL UNIT # 2 X VEHICLE PEDESTRIAN HIT & RUN OTHER
20 VEHICLE

4 Driver R NICHALOUS KUZIAN Driver MATTHEW JEROME TICCINO

First Middle Last Suffix First Middle Last Suffix
1
Address 615 BESS ST Address 826 RIDDICK CT
5

1 City WILMINGTON State NC Zip 28401 City WILMINGTON State NC Zip 28409 12

Driver's H ( 910 ) 343-3600 Driver's H ( 610 ) 620-5476 0

Same Address on Driver's Same Address on Driver's
Phone Phone 13
License? Yes X No Numbers W ( ) License? X Yes No Numbers W ( )

6 D.L. D.L.
D.L. # Class State NC D.L. # Class C State NC
2 CDL License CDL License
34Vision 35 Physical 36D.L. 34Vision 35 Physical 36D.L. 14
DOB
01/16/1985 Obstruction 0 Condition 1 Restrictions 9 DOB
06/23/1993 Obstruction 0 Condition 1 Restrictions 0
mm/dd/ccyy mm/dd/ccyy
8
37 Alcohol/ 38 Alcohol/ 39 Results 40 Vehicle 37 Alcohol/ 38 Alcohol/ 39 Results 40 Vehicle
7 Drugs Suspected 0 Drugs Test 0 (if known) 0 Seizure (DWI) Drugs Suspected 0 Drugs Test 0 (if known) 0 Seizure (DWI)
15

1 36
Owner CITY OF Owner ELYSE CLIFFORD TICCINO 16
Same as Driver? Same as Driver?

Address 205 OPERATIONS CENTER DR Address 826 RIDDICK CT

Same Address as Driver? Same Address as Driver?

City WILMINGTON State NC Zip 28401 City WILMINGTON State NC Zip 28409 17

84475T Plate NC Plate FFE2174 Plate NC Plate 2019 0

Plate # Plate #
State Year State Year 18

VIN 2B3LA43H08H206043 VIN 1FMFU18L14LA87412

X
DODG 2008 1 FORD 2004 4
Yes Yes 19
Vehicle Vehicle 41 Vehicle 42 Vehicle Vehicle Vehicle 41 Vehicle 42 Vehicle
Make Year Style (Type) Drivable X No Make Year Style (Type) Drivable No

43 TAD FD 3| | 44 Estimated $3,500.00 43 TAD BD 1| | 44 Estimated $2,000.00

Damage Damage
Insurance CHARTER OAK FIRE INSURANCE CO Insurance NC FARM BUREAU MUTUAL INS CO
Company Company

Policy # H8103039P493 Policy # APM 8381107

20 COMMERCIAL VEHICLE: Cargo, Carrier Name, Address, Source Carrier Identification Numbers, GVWR, Axles
Source:
Unit 45 Cargo Body Type Same Address as Owner?
Truck US DOT# ICC# Axles on Vehicle
Including Trailers

Shipping State State# IFTA#

papers

Driver Gross Vehicle

FEI# Fleet# Weight Rating

21 22 23 24 25 26 27 28 29 30 31 32 Names and Addresses for All Persons (Unit 1/Unit 2 Drv, Ped, etc. - See Above); Use check blocks if address same as Driver

1
Unit1-Drv1, Ped1, etc. see
A 1 1 1 see above W M 0 2 3 2 1 4 above Veh#___ Towed To/By: 230 GOVERNMENT CENTER EARLS TOWING
2
Unit2-Drv2, Ped2, etc. see
B 2 1 1 see above W M 2 1 3 2 1 5 above Veh#___ Towed To/By: DESTINATION BY DRIVER DESTINATION BY DRIVER
C

46 Name of EMS 46 Name of EMS

47 Injured Taken 47 Injured Taken
by EMS to (Treatment Facility and City or Town) by EMS to (Treatment Facility and City or Town)
 Form 2 of 4 Accident #: 2019001537
48 POINTS OF INITIAL
Unit# 1 2 1 3 VEHICLE INFO. Veh # 1 Veh # 2 ROADWAY INFO. WORK ZONE RELATED
CONTACT
(Write in Codes)
Unit# 2 15 16 14 60 Authorized Speed Limit
45 45 69 Road Feature
0 78 Workzone Area 5
1 2
79 Work Activity
CRASH SEQUENCE (Unit Level) Unit# Unit# 61 Estimate of Original Traveling Speed
35 0 70 Road Character
1
80 Work Area Marked
49 Vehicle Maneuver/Action
4 1 62 Estimate of Speed at Impact
32 0 71 Road Classification
5
81 Crash Location
50 Non-Motorist Action 63 Tire Impressions Before Impact (ft.) 72 Road Surface Type
3
TRAILER INFO. 1 2
3 3 3
51 Non-Motorist Location Prior to Impact 64 Distance Traveled After Impact (ft.) 73 Road Configuration Unit# Unit#

52 Crash Sequence - First Event for This Unit

21 21 65 Emergency Vehicle Use 74 Access Control
1 82 Trailer Type
00 00
53 Crash Sequence - Second Event " 66 Post Crash Fire (if "Yes" check block) 75 Number of Lanes
10 1st Trailer No. Axles

" Width (inches)

54 Crash Sequence - Third Event " 67 School Bus - Contact Vehicle 76 Traffic Control Type
0
Length (feet)
"
55 Crash Sequence - Fourth Event " 68 School Bus - Noncontact Vehicle 77 Traffic Control Oper
2 2nd Trailer No. Axles
56 Most Harmful Event for This Unit
21 21 COMMERCIAL VEHICLE: Hazardous Materials Involvement Width (inches)

0 0
57 Distance/Direction to Object Struck Haz Mat Placard Yes No From Placard indicate: Length (feet)

Hazardous Cargo 4-digit placard number or 1-digit number from 83 Unit# Overwidth Permit #
Yes No
58 Vehicle Underride/Override
3 3 Released (does not include fuel from fuel tank)
name from diamond or box bottom of diamond
Overwidth Trailer
and Overwidth
59 Vehicle Defects
0 0 Carrying Haz Mat Yes No Mobile Home

84 DIAGRAM

Indicate
North

X Traveling
X X Traveling
X
Unit# 1 was: Parked Facing N S E W on S COLLEGE RD Unit# 2 was: Parked Facing N S E W on S COLLEGE RD
(Include pertinent and unusual aspects,
85 NARRATIVE which are not listed elsewhere on the form)
I, Officer J. Knott, responded to a traffic crash in the 300 block of S. College Rd. on
01/15/2019 at 1736 hours.

Upon arrival I spoke to driver 2, Matthew Ticcino, whom stated he was operating vehicle 2,
NC tag FFE 2174, traveling south on S. College Rd. He stated he was stopped in traffic when
vehicle 1, NC tag 84475T, rear ended vehicle 2.

I spoke to driver 1, Officer R. Kuzian, whom stated he was operating vehicle 1 traveling
south on S. College Rd. He stated he was traveling approximately 35 mph when he looked at
his Mobile Data Terminal (MDT). Driver 1 stated he looked up and traffic was stopped and
hit the rear of vehicle 2.
State
ADDITIONAL PROPERTY DAMAGE Property?
86 Type/ Owner Address Estimated $
Owner Phone Damage

WITNESSES
Name Address Phone No. ( )

Name Address Phone No. ( )

TRAFFIC VIOLATION(S)
Name Charge(s)
(Citation # optional)
Name Charge(s)
Officer Name Officer Number Department Date of Report
PO KNOTT, J. F. PK8893 0650200 01/15/2019
 3 4
Form ______ of ______ Accident #: 2019001537

ACCIDENT DESCRIPTION (continued)

Upon my investigation I found Driver 1 failed to reduce speed in order to avoid a collision
and driving distracted.

Vehicle 1 suffered front end damage and was towed by Earls Towing to 230 Government Center
Dr. Vehicle 2 suffered minor rear end damage and remained drivable.

Driver 1 suffered a right leg injury. Driver 2 complained of no injuries.

City of Wilmington vehicle 0877 was involved in this collision and is listed as vehicle 1.

No further at this time.

Form 4 of 4 Accident #: 2019001537

DIAGRAM