HomeMy WebLinkAbout23-13090 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13090 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHI1.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF OZ OBJECT 1 1 8 28
UNITS
RESERVATION I I
STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 11 - 1-- 2023 1536 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SW 43RD ST BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4259990440 0 11
30
6� LAST NAME BLACKSTONE FIRSTNAME KATELYN MIDDLE E 1 2 31
INITIAL
STREET ❑✓ 19115 112TH AVE NE#307 CITY BOTHELL ST WA 2jp, 98011 z=
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� BYJ7894 sTArI WAurN# 4S46SENC1J3371053
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 5 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE ] $ 34
13 2 ZO18 SUBA OUTBA DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO KATELYN BLACKSTONE 11115112TH AVE NE APT 307 BOTHELL WA98011 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 948663821 4
IN EFFECT &POLICY# 9TOP
VEHICLE
15❑ 5 36
LECALLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:2063074800
LAST NAME THIND FIRST NAME KULJIT MIDDLE K
INITIAL
17❑ STREET ❑', 13229 SE 234TH ST CITY KENT ST WA ZIP 980423276 37
NEW ADDRE I I I I I ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICALt—TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES I�/]NO❑
19 DRIVER'S STATE WA ]SEX IF D.O.B. 05 _ 17 1973 39
LICENSE# MMDDYY
HELMET {NJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 USE 2 CLASS LEG PAIN ❑
21❑ LICENSE 1 BSC0546 TAre WA VIN# 5TDJZRFH1HS477931
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2017 MAKE TOYT MODEL HIGHLAN STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES�/ NO BANKERS YES NO
REGISTERED OWNER INFO MANJIT THIND 13229 SE 234TH ST KENT WA 98042 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 534 0319-1325-47IN CQ,
VEHICLE ❑ C—I CITATION# CHARGE io
LEGALLY YES N`LJ
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE22361
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13090
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) KRAMER SEAN K
(LAST FIRST,
ADDRESS&PHONE#
2708 156TH AVE SE BELlEVUE WA 98007 SEX M MMDDYyry 10 - 01 - 1993
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
✓� ❑ 1 POS. 3 2 4 1 USE 2 CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
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'
Unit 1 was in the center turn lane facing west in the 300 blk of SW 43rd ST planning to turn left into a
parking lot in the 8800 blk of S 180th ST (south side of 300 blk of SW 43rd ST). Unit 2 was traveling
eastbound in the far right of 3 eastbound lanes in the 300 blk of SW 43rd ST. The left and center
lanes of eastbound SW 43rd ST were backed up with traffic from a traffic light. These two lanes
stopped and provided enough room for Unit 1 to make the left turn across the eastbound lanes into
the parking lot. Driver 1 states they were unaware that Unit 2 was approaching in the far-right (south)
lane. Unit 1 initiated the left turn, failing to yield the right of way to Unit 2, and pulled into the path of
Unit 2 which was approaching. Unit 1 was impacted on the passenger side by the front end of Unit 2.
Unit 2 sustained heavy front-end damage and Driver 2 complained of leg pain and was transported to
Valley Medical Center for treatment. Unit 1 sustained moderate passenger side damage and was
able to drive from the scene. This report is to document the circumstances of the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 11-14-23 08:52 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 11/22/2023 10:35:47 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED; 3:41 PM TIME POLICE ARRIVED 3:49 PM
PART I PAGE IT]OF 3�
REPORT NO. EE22361 CASE# ' 23-13090 DATE AND TIME 11/13/23 15:36
OF COLLISION
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