HomeMy WebLinkAbout23-13868 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13868 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 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CawsloN 12 - 1-- 2023 2110 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 3RD ST BLOCK NO. e✓ 1900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FMILES EET e S ❑ W e MONTEREYDR NE
0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
NO ,/ D:2532665566 0 51
30
5� LAST NAME ROZIER FIRSTNAME MICHELLE MIDDLE M 1 2 31
INITIAL
STREET ❑, 800 YAUGER WAY SW UNIT C301 CITY OLYMP/A ST WA ZIP 985028914 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9� P1 ATE 14 455NSU STATE WA u N# 4S3BMCC65A3213542
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM ro
TRLR. TRLR 3 7 33
12 3 0 VIN#' VIN#
:: FROM TO
VEH.YEAR 2010 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 3 34
13 4 SUBA LEGACY SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO GLENN COATES 4207 NE FAILING ST PORTLAND OR 97213 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 947464432 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ NDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:2065384126
16 a
LAST NAME QAHER FIRST NAME KAMRAN MIDDLE N
INITIAL
17❑ STREET ❑', 510 STEVENS AVE SW APT R401 CITY RENTON ST WA ZIP 980575881 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LDI IVEW # STATE WA SEX M M D.C.B. 08 _ 13 _ 2004 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CET9921 TATE WA VIN# 19XF62F51DE268569
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2013 MAKE HOND MODEL CIV4D STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO AMANULLAH QAHER 13445 MARTIN LUTHER KING JR W SEATTLE WA 98178 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE INSU&PORGY#E CO NATL GEN INS 19XFB2F51DE268569 I STOP 5
IN EFFECT
VE"LE ❑ Nu,J CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES $ '
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE31301
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13868
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'
Both Units 1 and 2 traveling west along 1900 block of NE 3rd St past Monterey Dr NE. Unit 1 makes
abrupt U turn. Unit 2 rear ends Unit 1 causing non reportable non disabling front end damage to Unit
2 and non reportable non disabling damage to the rear of Unit 1. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 12-03-23 11:15 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1211712023 3:02:01 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED', 9:29 Pry TIME POLICE ARRIVED 9:26 PM
PART I PAGE IT]OF 3�
REPORT NO. EE31301 CASE# 23-13868 DATE AND TIME 12/03/23 21:10
OF COLLISION
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