HomeMy WebLinkAbout23-14780 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-14780 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 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 1950 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 1800
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 50 00 FEET e S ❑ W e I-405 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:3604543540 0 81
30
6� LAST NAME KORTAS FIRSTNAME JACK MIDDLE A 1 2 31
INITIAL
STREET 01 7426 LARRY PRICE LOOP RD#A CITY TULALIP ST WA ZIP 982716109 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVERS STATE WA SEX'M MM DAY' 05 1- 18 - 1953 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ Pi aT�S� B000382 sTAr� WAurN# 4A3AX35G5XE147156
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 4 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE R 34
13 1999 MITS ECLIPS CP DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO JACK KORTAS 7426 LARRY PRICE LOOP RD#A TULALIPWA982716109 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO NONE <1�3 4
LI EFFECT I SUR N# TOPVEHicLE CHARGE 36
LEGALLvYEs No clTAnoN# 3AO840001 OP MOT VEH W/OUT INSURANCEorrom
15❑ STANDING 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2068614152
16 a
LAST NAME PHAN FIRST NAME STEVEN MIDDLE
INITIAL
17❑ STREET ❑', 24822 237TH LN SE CITY MAPLE VALLEY ST WA ZIP 980385019 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YEs t l NoF,/
19 LDI IVER # STATE WA SEX M M D.C.B. 05 _ 10 _ 1955 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE ATM9981 TAre WA vIN# 5J6RM4H36FL003780
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2015 MAKE HOND MODEL CR-V EX STYLE SO VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO STEVEN PHAN 24822237TH LN SE MAPLE VALLEY WA 980385019 D:2068614152 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE I PORGY#E CO ALLSTATE 820510747IN I STOP
# CHARGE U
o BOLEGALYYES[Z N�
25❑ OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE35790
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14780
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY 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 2 traveling westbound on Maple Valley Hwy stopped at the light at the intersection of the
northbound 1-405 on ramp. Unit 1 also traveling westbound on Maple Valley Hwy approaching the
same intersection. Unit 1 followed too closely and failed to come to a stop before rear ending Unit 2
causing reportable non disabling front end damage to Unit 1 and reportable non disabling rear end
damage to Unit 2. No injuries reported. Unit 1 driver cited for following too closely and no vehicle
insurance. No evidence of impairment.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 12-25-23 09:03 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
J.CHRISTIANSEN 10437 12/31/2023 1:04:53 AM
BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 7:53 PM TIME POLICE ARRIVED 7:55 PM
PART I PAGE IT]OF
REPORT NO. EE35790 CASE# ' 23-14780 DATE AND TIME 12/25/23 19:50
OF COLLISION
u�
� i
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