HomeMy WebLinkAbout23-13061 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13061 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 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 0655 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BENSON DR S BLOCK NO. e✓ 3500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4252398337 0 6 30
6� LAST NAME VANDEBOGART FIRSTNAME TAWNIE MIDDLE N 1 1 2 31
INITIAL
STREET ❑, 8109 CROWN RIDGE BLVD CITY ARLINGTON ST WA ZIP 982234020 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� BKE0237 sTArI WAurN# 1G1JD6SB8H4102766
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 4 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T /g[ GOVT.VEHICLE 5 1 34
13 2 2017 CHEV SON/C 4T DAMAGE YES NoRS TOWING YES : No✓
REGISTERED OWNER INFO TAWNIE VANDEBOGAR18109 CROWN RIDGE BLVD ARLINGTON WA 98223 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 922307152
IN EFFECT &POLICY# 9TOP
15❑ vECEHA"LE 5 36
LLLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2533356254
16 2
LAST NAME AFRASOVA FIRST NAME SYUZANA MIDDLE M
INITIAL
17❑ STREET ❑', 12507 SE 265TH CT CITY KENT ST WA ZIP 980308673 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19 DRIVER'S STATE WA ]SEX IF D.C.B. O6 _ 15 _ 1995 39
LICENSE# MMDDYY
WELMET INJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 USE CLASS BACK PAIN ❑
21❑ 1 LICENSE CAY3582 TAre WA YIN# KM8R7DHE4NU390736
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2022 MAKE HYUN MODEL PALISAD STYLE UT VEHICLETOWED TO BLIN TOWED BY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO NADIM IZZATOV 12507 SE 265TH CT KENT WA 98030 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 4681899-D22-47BIN 1 9TOP
VEHICLE ❑ ,.I—I CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES N
s e
7JEE
S NAME(PRINT) OFFICER PHONE BADGE OR ID# FENCY
26
VANDERHOEK 11631 A0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE19197
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13061
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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'
Vehicle #1 was traveling northbound in the 3500 block of Bensen Dr S. Vehicle #2 was traveling
northbound in the 3500 block of Benson Dr S, directly in front of vehicle #1. Vehicle #2 started to
slow for stopped traffic in front of it. Vehicle #1 attempted to slow down for vehicle #2, but was
unable to slow in time to avoid a collision. The front end of vehicle #1 collided with the rear end of
vehicle #2. Based on the totality of the circumstances, it appeared vehicle #1 caused this collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 11-13-23 08:55 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 1111312023 1:51:38 PM
BADGE OR ID# 11631 ORI# ( WA0171300 TIME POLICE DISPATCHED; 7:09 AM TIME POLICE ARRIVED',7:12 AM
FART I PAGE IT]OF 3�
REPORT NO.! EE19197 CASE# ' 23-13061 DATE AND TIME 11/13/23 06:55
OF COLLISION
Nolt to scale
Vehl'*cle# -a'
Vehicle # 1�1.1-
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