HomeMy WebLinkAbout23-12660 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-12660 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 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 11 - 1-- 2023 1010 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
e✓ --- ----�
N 3RD ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET) BLOCK NO.
5❑ 200 00 FMILES EET e S ❑ W e SUNSET BLVD N
2 0 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO ✓ D:2066789600 0 11
30
6� LAST NAME JUWARA FIRSTNAME ALI MIDDLE N 1 2 31
INITIAL
STREET ❑, 12830 60TH LN S APT F4 CITY SEATTLE ST WA 2jp, 981783593 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVERS STATE WA SEX'M MM DAY' 07 1— 12 — 1990 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 ATFBit CGW2787 sTATI WA vIN#' 4T18E32KX5U596711
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# ROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
>;. FROM TO
VEH.YEAR ZOOS MAKE TOYT MODEL CAMRY STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
DAMAGE YES NO ✓ YES[:] NO✓
13❑ REGISTERED OWNER INFO ALIJUINARA1283060THLNSAPTF4 SEATTLEINA98178 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO GEICO 614170 90 11 3 4
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR ✓ PEDAL PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE- ❑ ❑ OWNER [:]EA.
YEs No ,/ D:4257612435
16 a
LAST NAME DORSEY FIRST NAME JUDITH MIDDLE I M
INITIAL
17❑ STREET ❑', 13322 178TH AVE SE CITY RENTON ST WA ZIP 980590000 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19 DRIVER # STATE WA SEX F M D.C.B. 11 17 1955 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE B15632G TATe WA VIN# 1FBNE31L26DA61874
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2006 MAKE FORD MODEL ECONOLI STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO JAMES DORSEY 13322178TH AVE SERENTONWA98059 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO ALL STATE INS 076 677 088IN IGQI
VE""LE ❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J.M/TCHELL 10377 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE18553
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12660
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) WILSON JESSICA
(IAST FIRST,
ADDRESS&PHONE# D O.B.
4257614583 SEX' U MMDDYYYY -❑
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
'(LASTr FIRS' MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT I 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'
On 110323 1 responded to a 2-vehicle non-injury collision just west of Sunset Blvd N on N 3rd.
I contacted the driver of unit 2 who told me they were traveling in the #2 lane of eastbound N 3rd
when unit 1 entered lane 2 (from lane 1). Driver of unit 2 says the action of unit 1 caused the vehicles
to collide.
I contacted the driver of unit 1 who told me they were traveling in the #1 lane of eastbound N 3rd
when unit 2 entered lane 1 (from lane 2). Driver says the action of unit 1 caused the vehicles to
collide.
I contacted the witness who told me they were traveling in the #2 lane of eastbound N 3rd (one car
length behind unit 2) and witnessed unit 1 make a lane change from lane 1 to lane 2 and collide with
unit 2.
But not for the action of UNIT 1 DRIVER the result would not have happened.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.MITCHELL 11-07-23 09:05 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 1111112023 7:09:24 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED 10:10 AM TIME POLICE ARRIVED',10:15 AM
PART I PAGE IT]OF 3�
REPORT NO.! EE18553 CASE# ' 23-12660 DATE AND TIME 11/03/23 10:10
OF COLLISION
Sunset Blvd N
WITNESS POt FIB r.
IOOOOO....I
N 3 ST
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