HomeMy WebLinkAbout23-4690 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-4690 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 04 - 1-- 2023 1510 17 ❑.❑ S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LIND AVE SW BLOCK NO. e✓ 1000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063724833 0 11
30
6� LAST NAME MOTON FIRSTNAME JOE MIDDLE D 1 2 31
INITIAL
STREET ❑✓ 4049 38TH AVE S CITY SEATTLE ST WA 2jp, 98118 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
❑ DRIVER'S' STATE AL SEX'M MI DAY' 07 - 02 1- 1968 1 2 32
8 LICENSE#
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 D.
H USEET 2 I INJURY CLASS 1 NATURE OF INJURIES 2❑
3
10 9� P1 ATE 14 AFJ6199 STATE WA VIN# 1 FMYU94135KA28090
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 5 1 34
13 2 2005 FORD ESCAPE DAMAGE vEs 0NO agW�MEYERS ves❑ No
REGISTERED OWNER INFO NAOMISELLERS 404938THAVE S SEATTLE WA 98118 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO STATE FARM 4915643-1503.47 4
IN EFFECT &POLICY# 1 9TOP
VawcLe CHARGE 5 36
ALLY YES❑NO CITATION# 3A0374737 FLD SIGNAL STOPS/TURNS-UNSAFE o Borro6
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:2533592214
16 a
LAST NAME GEHRMANN FIRST NAME JACOB MIDDLE IT
INITIAL
17❑ STREET ❑', 10005 22ND AVE E CITY' TACOMA ST WA ZIP 984455438 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES
F% NO❑
19 D IVEW # STATE WA SEX M M D.C.B. 11 01 2001 39
CENS —NATURE.1 INJURIES
W USE
EET LASS 6
Y ROAD RASH/CUTS/ABRASIONS LEFT BACK 40
20 ON DUTY STATUS AIRBAG, 1 RESTR 13 EJECT 3 5
21❑ LICENSE 4G3486 TATe WA VIN1 1HD1KTP1XL6644272
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
uIN#, N# 44
VEH YEAR 2020 MAKE Hp MODEL FLTRXS STYLE MC VEHICLE TOWED TO BLIN TOWED ev GOV HI
24❑ DAMAGE YES�/ NO JET CITY(SELF) YES No
REGISTERED OWNER INFO JEFFREY BELFORD 2I E ASPEN CT SHELTON WA 98584 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#ECO JET CITY HARLEY DAVIDSON SELF/CORPORATE STOP 5
IN EFFECT
'E""Le ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`[]
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 77T�NCY26K.LANE 10008 0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED55407
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4690
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SELLERS NAOMIJ
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
4049 38TH AVE S SEATTLE WA 981181107 2067537214 SEXi F MMDDYyry 03 - 30 - 1947
PASSENGER Z WITNESS UNIT# 1 PODS 3 AIRBAG 2 RESTR. 4 EJECT ? 1 HELMET NATURE OF INJURIES
USE 2 CLASS
'1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# Do.B
SEXt MMDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 was traveling behind Unit 1 as they traveled northbound in the 1000 blk of Lind AVE SW.
Driver 2 stated he pulled behind Unit 1 as there was a metro bus in the right of two northbound lanes.
Once past the bus, Unit 2 changed lanes into the right of two the two northbound lanes as Unit 1
continued in the left lane. As Unit 2 accelerated to pass Unit 1, Unit 1 initiated a lane change to the
right into the lane occupied by Unit 2. Unit 1 pulled into the path of Unit 2, which could not stop in
time, and the front end of Unit 2 impacted the passenger side of Unit 1. This impact caused
moderate/heavy damage to Unit 1 and Unit 2 was thrown to the ground with Rider 2 thrown off the
motorcycle. Rider 2 sustained road abrasions and injury to the left arm and side of his body. Rider 2
was transported to VMC for treatment. Unit 1 towed by Gene Meyers. Unit 2 was being transported
from Jet City Harley Davidson by Jet City employee's and was under their possession from the
registered owner. Unit 2 sustained heavy front end and side damage and was towed by Jet City.
Driver 1 cited for the unsafe lane change by changing lanes without assuring this could be done
safely and pulled into the area occupied by Unit 2 which was the proximate cause of the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 04-26-23 04:34 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 412812023 2:44:16 PM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 3:12 PM TIME POLICE ARRIVED',3:18 PM
PART I PAGE IT]OF
REPORT NO. ED55407 CASE# ' 23-4690 DATE AND TIME 04/26/23 15:10
OF COLLISION
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