HomeMy WebLinkAbout23-12700 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-12700 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC WA0171.300 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TRIBAL 02
TOTAL#OF OBJECT 1 1 8 28
UNITS ❑
RESERVATION I I
STRUCK z
3 M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
c usloN' 11 - 05 - 2023 0702 17 ❑-= E IN e 1070 3
S 8
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 3RD PL BLOCK NO. e ❑
MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e RA/N/NER AVE S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:2066813093 0 11
30
6� LAST NAME ALASROMAN FIRSTNAME WILFREDO MIDDLE 1 1 2 31
INITIAL
STREET ❑ 813 SW 363RD PL CITY FEDERAL WAY ST WA 2jp, 98023 z
'NEW ADDRESS
7❑ 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 HELMET 2 INJURY 6 NATURE OF INJURIES z❑
USE CLASS PAIN LEFT ARM/LOST HEARING IN LEFT EAR
3
10[1Pl QEES# CGK2744 STATE WA VIN#' 19XFL2H89PE015802
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# Rom ro
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
FROM TO
❑ VEH.YEAR 2023 HOND CIVIC SD MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 4 DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO ENTERPRISE FM TRUST 1115 OLIVE BLVD SAINT LOUIS MO 63132 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE z INSURANCE CO PROGRESSIVE 952141850 4
LI EFFECT I POLICY# TOPVE—LE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4255246446
16 a
LAST NAME NEISINGER FIRST NAME MICHAEL MIDDLE IS
INITIAL
17 STREET IS❑' 2201 MAPLE VALLEY HIGHWAY APT 61 CITY' MAPLE VALLEY ST WA ZIP 98057 4❑ 37
NEW ADDRES
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCKYEs❑No� INTERLOCK ves No� YES NDF
19 LICENSE STATE WA SEX M I D.MMDDYY 12 _ 22 _ 1970 39
20❑ ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 WEB SET 2 NJAURSY 6 COMPLAINT OF PAIN TO BACK ❑F—NATUREOF INJURIES 40
❑21❑ PLATE# C69313Z TATE WA VIN# 41
STFUU4ENSDX078962 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2013 MAKE TOYT MODEL TACOMA STYLE PK VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO MICHAEL NEISINGER 2201 MAPLE VALLEY HIGHWAY APT 6I MAPLE VALLEY WA 98057 D:4255246446 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE INSU&PORGY#E CO FEDERAL MUTUAL INSURANCE 1825096 1 9TOP
IN EFFECT
V
EHICLE ❑ NC[—] CITATION# CHARGE io BOTTOM
YES
25 $
'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
HYNES 12612 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE17830
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12700
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) UNKNOWN WILL
(LAST FIRST,
ADDRESS&PHONE#
UNKNOWN UNKNOWN RENTON WA 2063903888 SEX M MMDOYyry -�-
PASSENGER WITNESS UN T# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ POS. USE CLASS
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&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ROSEANNE HYNES 11-05-23 02:13 PM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 111812023 12:57:26 PM
BADGE OR ID# ( 12612 OR]# WA0171300 TIME POLICE DISPATCHED; 7:03 AM TIME POLICE ARRIVED',7:10 AM
FART I PAGE IT]OF 4�
REPORT NO. EE17830 CASE# 23-12700 OF COLLISION
11/05/23 07:02
OF CbLLI510N
NARRATIVE
On 11/04/2023 at 0703 hours, I was in full patrol uniform and driving a marked Renton Police patrol
vehicle when I was dispatched to Renton Center Way and Rainier Ave S in the city of Renton, County
of King, State of Washington regarding a traffic collision.
Upon arrival, Officer S. Fajarillo was on scene and speaking with Driver 2 (D2) -Michael S. Neisinger.
Officer Fajarillo said that D2 stated in summary: He was driving north on Rainier Ave S approaching
the intersection at S 3rd PL. He had a green light. As he drove through the intersection, he was struck
by Vehicle 1 (V1). He complained of pain to his back but declined medical assistance. I saw severe
damage to the rear left side of his vehicle (V2). The left side curtain airbags had been deployed in his
vehicle. His vehicle was privately towed from the scene. Officer Fajarillo further stated there was a
witness on scene whose statements concurred with D2's statements. He has been entered in this
report as a witness. He was not on scene when I arrived.
I spoke with Driver 1 (D1) -Wilfredo Alasroman and he told me in summary: He was driving west on S
3rd PL approaching the intersection at Rainier Ave S. As he drove through the intersection he looked
at his clock and he collided with V2. I asked D1 if he knew what color the light was and he said he
believed it was red. He complained of pain to his left arm and said he lost some hearing in his left ear.
He declined medical assistance. I saw severe damage to the front of V1. The driver airbag and left
side curtain airbags had been deployed. V1 was privately towed from the scene.
I have nothing further.
This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed: R. Hynes #12612 Date & Place: 11/05/2023 @ 1340 hrs Renton, WA
PAGE 3 OF 4
REPORT NO.! EE17830 CASE# ' 23-12700 DATE AND TIME 11/055/23 07:02
OF COLLISION
.7
*Not Drawn to
ate
PAGE 4 OF 4