HomeMy WebLinkAbout23-12728 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. EE27737 170
27
COLLISION REP FIT 1591971
CASE 23-12728 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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 1912 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
N 3RD ST BLOCK e✓ 700
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 20 00 FMILES EET e S B W e BURNETTEAVEN
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:8455949373 0 11
30
6❑ LAST NAME MADIGAN FIRSTNAME JACK MIDDLE P 1 1 2 31
INITIAL
STREET ❑, 12 STORTINI DR CITY R CORNER ST NY ZIP', 12572 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE NY SEX'M MD.
MDDYY 05 - 31 1- 2001 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USEET 2 I INJURY CLASS 1 NATURE OF INJURIES 2❑
3
10 1❑ LICENS P1 ATE 14 JPF2686 sTAT NY vN# M011245928468413469
F_ TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FR.. To
TRLR. YRLR. 3 3 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T k GOVT.VEHICLE 3 3 34
13 2019 VOLK JETTA SD DAMAGE YES NO � '` RS YES❑ No✓
REGISTERED OWNER INFO JACK MADIGAN 12 STORTINI DR R CORNER NY 12572 D:8455949373 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ABILI INSURANCE❑ NSURANCE CO 4
LI EFFECT &POLICY# 9TOP
VENICLE CHARGE 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2063066558
16 a
LAST NAME REED-BENNET FIRST NAME JUSTIN MIDDLE T
INITIAL
17 STREET ADDREs�' 11844 55TH AVE S CITY SEATAC ST WA ZIP 98178 37
� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER # STATE WA SEX M M.C.B. 01 27 1992 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
❑ 41
21❑ PLATE# CFG0639 rare WA VIN# 1FTYR2ZM5FKA62338 1
42
22❑ PLATE# STATE PLATE ILER# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2015 MAKE FORD MODEL TRANSIT STYLE VN VEHICLE TOWED TO BLIN TOWEDeY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO JUSTIN REED-BENNET 118"55TH AVE S SEA WA 98178 D:2063066558 VEHICLE NO.2
SHADE DA GEbAREA
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I ve E ❑ ,J� CITATION# CHARGE25 GQ
LEGALLY YES N J
s 7 6
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
JASON TURNER 12650 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE27737
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12728
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 was driving east bound on N 3rd ST in straight line in the left most lane. Unit 1 was driving east
bound on N 3rd ST in the lane directly next to Unit 2. Unit 1 attempted to merge into left most lane but
merged directly into Unit 2's vehicle. Unit 1 stated that they did not check their blind spot before
making the lane change.
Neither party was injured. Unit 1 had numerous airbags deploy in the vehicle. The driver's side of the
vehicle had significant damage and the vehicle was leaking fluid. A personal tow was called for Unit
1's vehicle.
Unit 2 had significant damage to the passenger side of their vehicle, but the vehicle was still
driveable. The damage appeared to be over $1000.
I created an exchagne of information for both parties.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON TURNER 11-05-23 03:13 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1 121712023 2:23:27 AM
BADGE OR ID# 12650 ORI# WA0171300 TIME POLICE DISPATCHED; 7:92 Pry TIME POLICE ARRIVED'7:12 PM
PART I PAGE IT]OF 3�
REPORT NO. EE27737 CASE# ' 23-12728 DATE AND TIME 11/04/23 19:12
OF COLLISION
N
NOMINEE
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