HomeMy WebLinkAbout24-2294 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-2294 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT 8 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 03 - 01 - 2024 1845 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
ROUSER WAYS BLOCK NO. e✓ 1200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e MAIN AVE S
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4253066588 0 3 30
gF] LAST NAME BURDIN FIRSTNAME VAL MIDDLE 1 2 31
INITIAL
STREET ❑1 27116 117TH PL SE CITY KENT ST WA 2jp, 98030 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
LOB 10 1- 26 - 1964 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ Pi aTES� CBL7111 sTATe WAurN# 1 C4RJFBG5MC840877
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 3 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN 5 3 TOWED BY GOVT.VEHICLE 34
13� 2021 JEEP GRAND P4 DAMAGE YES NO YES[:] No
✓
REGISTEREDOWNER WFO CCAP AUTO LEASE LTD ROB INSURANCE SERVICES IN 6225 LAKE WASHINGTON BLVD NE KIRKLAND WA 98033 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE NPOLICY E CO GEICO 6042327368 4
LI EFFECT &POLICY# TOPVEHICLE CHARGE36
LEGALLv YES❑NO CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16 a UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:4255177945
LAST NAME MC GEE FIRST NAME ALLEN MIDDLE
INITIAL
17❑ STREET —NEW ADOREss❑' 1087 LAKE WASHINGTON BLVD N, CITY RENTON ST WA ZIP 98056 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19[ LDI IVER # STATE WA SEX M M .O.B. 05 _ 17 1959 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑21❑ PLATE# 41
C16864W TATE WA VIN# 5TFEM5F17CX045116 1
42
22❑ PLATE# STATE TILER PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2012 MAKE TOYT MODEL TUNDRA STYLE TR VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ALLEN MCGEE 1087 LAKE WASHINGTON BLVD N,RENTON WA 98056 D:4255177945 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU8 PORGY#E CO USAA 0194332167101IN I 9TOP 5
VEHICLE ❑ I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES NC
25 s e
7m-
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
FERNANDES 12848 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE61836
COLLISION REPORT III III III III III 111
1591972 CASE# 24-2294
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,FIRS 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 IN THE EAST LANE MAKING A RIGHT TURN WHILE VEHICLE 2 WAS IN THE
WEST LANE MAKING A RIGHT TURN. VEHICLE 1 STRUCK THE REAR RIGHT QUARTERPANEL
OF VEHICLE 2 CAUSING MINOR DAMAGE TO VEHICLE 2. THE FRONT BUMPER FROM
VEHICLE 1 WAS RIPPED OFF. THERE WERE NO REPORTED INJURIES. BOTH DRIVERS
ALLEGED THAT THE OTHER DRIVER ENTERED THEIR LANE CAUSING THE COLLISION. I WAS
UNABLE TO DETERMINE WHICH VEHICLE WAS AT FAULT BASED ON THE DAMAGE.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
MAR/A FERNANDES 03-04-24 02:22 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 3/23/2024 4:11:53 PM
BADGE OR ID# 12848 ORI# WA0171300 TIME POLICE DISPATCHED; 6:53 PM TIME POLICE ARRIVED',6:58 PM
PART Ei PAGE IT]OF
REPORT NO. EE61836 CASE# 24-2294 DATE AND TIME 03/01/2418:45
OF COLLISION
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