HomeMy WebLinkAbout23-06335 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-06335 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 2$
5 0
RESERVATION
TRIBAL UNITS 02 STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 06 - 04 - 2023 1824 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SUNSET BLVD N BLOCK NO. e✓ 1600 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a BRONSON WAYN
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLDPHONE
UNIT 01 VEHICLE ❑ CYCLE El MET YES ✓NO D:6467054112 0 11
30
6� LAST NAME NAIR FIRSTNAME RAXT MIDDLE 1 2 31
INITIAL
STREET ❑ 813 MT BAKER PL NE CITY RENTON ST WA 2jp, 98059 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ P1 ATNES# BCJ4821 sTAr WA v N# 19UU63F72GA003411
11[-jTRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# IR.. ro
TRLR. A'RLR. 1 5 33
12 3 0 VIN#' VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 3 ] 34
13 3 2016 ACUR TLX SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 901345302 4
LI EFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2062762458
16 a
LAST NAME EAGER FIRST NAME RUSSELL MIDDLE lK
INITIAL
17❑ STREET ❑', 253 THOMAS AV SW CITY' RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19[-] DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE AOB9878 TATE WA VIN1 1GNDT13S272263723
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2007 MAKE CHEV MODEL TRAIL STYLE $V DAMAGE TOWED NOO✓ B TOWED BY ov HLIN yES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE DAGELLAREA
LIABILITY INSURANCE I PORGY#ECO HARTFORD CASUALTY 55PHT315599 5
IN EFFECT
VE"LE ❑ ,J� CITATION# CHARGE C�Q
LEGALLY YES N`L J
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED72490
COLLISION REPORT III III III III III 111
1591972 CASE# 23-06335
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) NAIR PONNAMMMA
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
6333 98TH PL 4A REGO PARK NY 11374 SEXi F MMDDYyYY 05 - 21 - 1947
PASSENGER Z WITNESS❑,UNIT# 1 SOS 3 AIRBAG 2 RESTR. q EJECT ? 1 HELMET INJURY NATURE OF INJURIES
USE CLASS {1
NAME
(LAST,FIRST,MIDDLE INITIAL) CHAKKALAKKAL RAVINDRAN
ADDRESS&PHONE# D O B
1008 SWEET BREEZE DR VALRICO FL 33594 SEX' M MMDDuvvT 11 _ 10 _ 1955
SEAT HELMET I INJURY NATURE of INJURIES
PASSENGER Z WITNESS UNIT# 1 POS. 9 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) SANTHA CHAKKALAKKAL
ADDREss&PHONE# 1008 SWEET BREEZE DR VALRICO FL 33594 SEX F 04 03 _ 1957
. .B.
M D.O _
MDDYYYY
PASSENGER WITNESS UNIT# ! 1 SEAT 7 AIRBAG 2 RESTR. 4 EJECT 1 HELMET NJURY 1 NATURE OF INJURIES
❑ SEATPOS. USE CLASS �F----�
NARRATIVE'
Unit 1 traveling south on Sunset Blvd N approaching intersection of Bronson Way N. Unit 2 traveling
west on Bronson Way N approaching intersection of Sunset Blvd N. Unit 1 driver reported having
green light at intersection. Unit 2 driver reported being confused by ambulance, train crossing lights,
and other traffic. Unit 1 collides with Unit 2 causing reportable non disabling front end damage to Unit
1 and reportable disabling passenger side damage to Unit 2. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 06-04-23 08:05 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 6/22/2023 3:28:04 AM
BADGE OR ID# 12651 OR]# WA0171300 TIME POLICE DISPATCHED 6:37 PM TIME POLICE ARRIVED f 6:41 PM
PART I PAGE IT]OF 4]
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED72490
COLLISION REPORT III III III III III 111
1591972 CASE# 23-06335
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) ROGERS REBECCA L
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
427 WELLS AV S RENTON WA 98057 SEXi F MMDDYyry 11 - 04 - 1964
PASSENGER Z WITNESS❑'UNIT# 2 PEEA 3 AIRBAG'2 RESTR. q EJECT ? HELMET INJURY NATURE OF INJURIES
OS. USE CLASS 11
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 traveling south on Sunset Blvd N approaching intersection of Bronson Way N. Unit 2 traveling
west on Bronson Way N approaching intersection of Sunset Blvd N. Unit 1 driver reported having
green light at intersection. Unit 2 driver reported being confused by ambulance, train crossing lights,
and other traffic. Unit 1 collides with Unit 2 causing reportable non disabling front end damage to Unit
1 and reportable disabling passenger side damage to Unit 2. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 06-04-23 08:05 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 6/22/2023 3:28:04 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED 6:37 PM TIME POLICE ARRIVED f 6:41 PM
PART I PAGE 3�OF 4�
REPORT NO. ED72490 CASE# ' 23-06335 DATE AND TIME 06/04/23 18:24
OF COLLISION
NOT TO SCALE
PAGE 4 OF 4