HomeMy WebLinkAbout23-12592 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 88 27c
COLLISION REP FIT 1591971
FIRE CASE## 23-12592 2
INTERSTATE CITY STREET ❑ RESULTED ❑
1 ❑STATE ROUTE OTHER STOLEN❑ H F ❑ LOCAL AOENC 3
HIT IT&&RUN CODING
COUNTY RD � PRIVATE WAY � INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 01 STRUCK STREETLIGHT POLE
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GawsloN 11 - 1-- 2023 0121 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
2431 MAPLE VALLEY HW BLOCK NO. e✓ 2400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FMILES NEET e S ❑ E e BLA/NE DRIVE SE
0 2 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE =30
6� LAST NAME JOHNSON FIRSTNAME MATTHEW MIDDLE D 1 1 2 31
INITIAL
STREET ❑ 3827 W MEADOWBRANCH CITY COEUR D ALENE ST /D 2jp, 83814 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO Z/ INTERLOCKYEs NO�/ YEs No�/
8❑ DRIVERS
# STATE JD SEXI M I D-MMDDYY' 06 - 24 - 1977 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 9 EJECT 1 H USE CLASS
2 CLASS 1 NATURE OF INJURIES 2❑
3
10 P1 ATE 14 K76520 sTATe ID v N# JF1 SG65694H753897
TRAILER STATE TRAILER STATE
11 4 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12❑ VIN#j VIN#
FROM
34
13❑ VEH.YEAR2004 MAKE SUBA MODEL FOREST STYLE 4D VEHICLE TOWED NOOpLSABLIN TSIYYEp9vMEYERS VEHICLE
DAMAGE IILLJJII (��IV6
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ UABILI V INSURANCE❑ INSURANCE CO PROGRESSIVE 933437501 4
IN EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STAIN.D'ING 7 6
UNIT VE IOOR El CYCLE PEDAL- ❑ PEDESTRIAN ❑ OWNER
❑ DYES H OLD MET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YES❑NO❑
19 LLIRIVERISTICENS # STATE SEX MMDDYY —�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TATE IN# 41
V 1
PLATE#
42
22❑ PIR I I TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
7PETERSON
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
12808 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE20374
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12592
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'
Case#23-12592
On 11/02/2023 at approximately 0124 hours I was dispatched to an accident with unknown injury at
2431 Maple Valley highway in the City of Renton, County of King, State of Washington.
While enroute, dispatch advised that a vehicle was out front of above location and had hit an
electrical box. There was unknow injuries at this time.
Upon arrival, I saw a gentleman later identified by his IDDL as Matthew D. Johnson (DOB
06/24/1977) he was standing outside of his vehicle a Gold 2004 Subaru Forester (ID plate K76520/
VIN JF1SG65694H753897). I contacted Matthew, and I asked if he needed medical attention but he
declined. Matthew stated he was trying to pass a vehicle and when he turned due to the wet
conditions, he slide off the road and smashed into the light poll.
I requested a tow for Matthew and once the tow arrived, I gave him a citizen's transport to where he
was staying.
I gave Matthew a business card with the case number he could reference for his insurance.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed: Officer Kevin L. Peterson Date and Place: 11/02/2023, 0250 hours at Renton,
WA
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 11-02-23 03:03 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 888 1 1111612023 4:31:58 PM
BADGE OR ID# ! 1Y808 ORI#' WA0171300 TIME POLICE DISPATCHED; 1:24 AM TIME POLICE ARRIVED',4:26 AM
PART I PAGE IT]OF 3�
REPORT NO. EE20374 CASE# ' 23-12592 DATE AND TIME 11/02/23 01:21
OF COLLISION
Model not to scale
Maple Walley HWY
ir
car contacting pall
PAGE 3 OF 3