HomeMy WebLinkAbout23-13996 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13996 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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# ❑
COLLISION.. 12 - 1-— 2023 1031 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BENSON DR S BLOCK NO. e✓ p ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ W e S PUGET DR
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4255243793 0 6 30
6� LAST NAME SMITH FIRSTNAME SHELBY MIDDLE L 1 1 2 31
INITIAL
STREET ❑✓ 23260 105TH AVE SE CITY KENT ST I WA 2jp, 98031 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YEs 1/ NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELMET 2 INJURY 6 NATURE OF INJURIES z❑
USE CLASS UPPER BODY/AIRBAG INJURY
3
10[1PI ATE 14 CFX4911 STATE WA u N#' 3N1CB51 D52L660677
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# 1R.. ro
TRLR. YRLR. 5 1 33
12 3 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 1 34
13 2 2002 NISS SENTRA DAMAGE vE5 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO SHELBYSMEEH 7922 S 125TH ST SEATTLE WA 98178 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
LEGALE CHARGE to BOTTOM 5 36
LEGALLY YEs No clTAnoN# 3A0668515,3A0668515 INATTENTIVE DRIVING,OP MOT VEH
15❑ STANDING 7 6
MOTOR PEDAL- 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2535459098
16 a
LAST NAME HUD FIRST NAME NATALIIA MIDDLE
INITIAL
17❑ STREET �', 24515 102ND PL SE CITY' KENT ST WA Zip 98030 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED ❑ 38
INTERLOCKYES�NOF INTERLOCK YEs❑NOF YES
❑NOF,/
19 F] DRIVERIS
{NJURY RE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS 1 NATU ❑
21❑ LICENSE I CGB9691 TATE WA VIN# JTDKN3DU5A0053481
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2010 MAKE TOYT MODEL PRIUS STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO NATALIIA HUD 24515102NDPL SE KENTWA98030 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO STATE FARM 1489-5516-15IN 1GD
VEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`E]
25 s � a
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. EE32817
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13996
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 1 was traveling some distance behind Unit 2 on northbound Benson DR S approaching a traffic
signal at S Puget DR. This traffic signal turned yellow and Unit 2 applied its brakes to slow for this
pending red light. Driver 1 stated that they applied the brakes but due to the vehicle speed on the wet
roadway with a grade, the tires locked and it began to skid. Unit 1 failed to stop in time and the front
end of Unit 1 struck the rear end of Unit 2. Unit 1 sustained heavy and disabling front end damage.
Unit 2 sustained moderate rear end damage. Driver 1 advised Unit 1 was uninsured. Driver 1 was
treated at the scene by Renton AID and transported to Valley Medical Center for a potential upper
body/airbag injury. Unit 1 towed by Bankers Tow.
Driver 1 cited for Inattentive Driving by not driving with due care and caution to the vehicle roadway
conditions, grade, and their vehicle speed and for not seeing the yellow light, a common braking
scenario, to reacting and brake in time which was the proximate cause 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 12-06-23 11:53 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 12/21/2023 7:47:12 AM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED' 10:33 AM TIME POLICE ARRIVED 10:36 AM
PART I PAGE IT]OF
REPORT NO. EE32817 CASE# ' 23-13996 DATE AND TIME 12/06/23 10:31
OF COLLISION
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