HomeMy WebLinkAbout23-14755 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-14755 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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 12 - 1-- 2023 1201 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
108TH AVE SE BLOCK NO. e✓ 17900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 75 00 FEET MILES e S B W e SE180TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:3604408140 0 81
30
6� LAST NAME MORGAN FIRSTNAME SIDNEE MIDDLE N 1 2 31
INITIAL
STREET ❑, 17735 105TH PL SE CITY RENTON FT WA 21p, 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO,/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVERS STATE WA SEX'F MID
.O B 11 1— 27 — 2000 1 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ Pi aT�S� CHt3077 sTArr WAurN# KMHFC46FX6A0996f0
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 5 33
12 3 5 VIN#j VIN#
FROM TO
VEH.YEAR 2006 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 9 34
13 HYUN AZERA 4D DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO SIDNEE MORGAN 11735105TH PL SE RENTON WA 98055 D:3604408140 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
Ela.e CHARGE 5 36
LvECALHLv res❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UN�T 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YEs NO ,/ D:4256813525
16 a
LAST NAME BOLT FIRST NAME SARAH MIDDLE A
INITIAL
17❑ STREET ❑', 21128 127TH PL SE CITY' KENT ST WA ZIP 98031 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs❑NOF YES
❑NO/
19 LICENSE# STATE WA ]SEX IF M DDY
.C... 04 1f 1995 39
HELMET INJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CGE7976 TAre WA VIN# Y►/4H60CX2P1938304
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2023 MAKE VDtV MODEL XC90 STYLE $W DEHICLEAMAGE TOWED NOO✓ BLIN TOWED BY OV HYES NO,/ 44
24❑ fj
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO GEIC04618935037IN 1 GD
LEGALLY YES Nu
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE37386
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14755
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) BOLT LYNN J
(I.P.ST FIRST,
ADDRESS&PHONE#
21128 127TH PL SE KENT WA 98031 8505861312 SEXi F MMDDYyry 04 - 01 - 1956
PASSENGER WITNESS UMT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 2 POS. 3 2 4 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O E4
SEX MMDDVYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 exiting driveway from 17901 108th Ave SE onto southbound 108th Ave SE. Unit 2 standing in
left turn lane, southbound 108th Ave SE at SE 180th St. Driver 1 Morgan told me that she was
watching approaching traffic coming southbound as she attempted to merge into the left turn lane,
and did not see that Unit 2 was stopped in her path. Driver 2 Bolt told me that she was stopped in the
left turn lane for traffic signal when Unit 1 struck her car from behind. No injuries; only a small paint
chip on Unit 2's rear bumper, but Bolt told me that a similar collision had resulted in about $4000 in
repairs to her bumper and all sensors in her 2023 Volvo. Morgan told me that she did not have any
liability insurance on her car, and was driving on an expired license. Issued an NOI via complaint to
Morgan for no insurance, warned her on expired license (less than one month past expiration).
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 12-24-23 07:06 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.MOYNIHAN 1128E 1 11512024 12:58:33 AM
BADGE OR ID# 15738 ORI#' WA0171300 TIME POLICE DISPATCHED! 4Y:08 PM TIME POLICE ARRIVED 12:13 PM
PART I PAGE IT]OF 3�
REPORT NO. EE37386 CASE# ' 23-14755 DATE AND TIME 12/24/23 12:01
OF COLLISION
nit .
Unit 2
� l
i
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