HomeMy WebLinkAbout24-1447 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-1447 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 03 STRUCK
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
COLLISION'. 02 - 09 - 2024 1327 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAIN AVE S BLOCK NO. e✓ 228
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:4254027392 1 4 30
6� LAST NAME SUC/U FIRSTNAME BENJAMIN MIDDLE E 1 1 2 31
INITIAL
STREET ❑ 4626 NE 24TH ST CITY RENTON ST WA 21p 98059 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YEs NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES z❑
3
LICENSE CKG6976 STATE WA u N#
10❑ Pr ATE�
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLINTOWED BY GOVT.VEHICLE J ] 34
2 2022 DODG DART SD DAMAGE vesNo ves❑ No 1/13
REGISTERED OWNER INFO ELENA SUCIU 5219 NE 11TH CT RENTON WA 98059 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCECO ALLSTATES17335757
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv Yes❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
MOTOR PEDAL- ❑ PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ OWNER ❑ YES 1/ No D:4065310795
16❑
LAST NAME EGGEBRECHT FIRST NAME DOUGLAS MIDDLE I J
INITIAL
17 NEW STREETR 7' 11044 SE 192ND STREET CITY RENTON ST WA ZIP 980557432 37
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19[—] LDI IVEW # STATE WA SEX M MMDDW 04 25 _ 1962 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 1 EJECT '1 USE 2 CLASS ❑
❑ILICENSE 21❑ PLA E# B26673H TATe 41
WA VIN# 1B7ME3689KS139942 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 1989 MAKE DODG MODEL D3PU STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO DOUGLAS EGGEBRECHT 11044 SE 192ND STREET RENTON WA 980557432 VEHICLE NO.2
SHADEDAMAGEbAREA
s Cd
LIABILITY
INSURANCE 8POINSURGY#ECO STATE FARM 4486292 D2047AIN STOP
VE""LE ❑ ,J CITATION# CHARGE io BOTTOM
LEGALLY YES Nu
25 7CA
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26LAN 12007 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE50268
COLLISION REPORT III III III III III 111
1591972 CASE# 24-1447
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'
On February 09, 2024 at 1327 hours dispatch requested that I respond to a collision near the
intersection of Main Ave S and S 2nd St.
Upon my arrival I learned that this was a three vehicle collision. Two of the three vehicles were
unoccupied and parked along the side of Main Ave S. Passerbys stated that unit 1 failed to stay in
their lane, striking unit 2 from behind. The collision then pushed unit 2 into unit 3. Unit 1 and 2
sustained severe damage that disabled both vehicles, requiring them to be towed. Unit 3 was
drivable.
I then spoke with the driver of unit 1 and they explained they failed to stay in their lane, hitting unit 2
from behind.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.CATALAN 02-09-24 04:41 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 2/13/2024 10:53:29 AM
BADGE OR ID# 1Y007 OR]#' ' WA0171300 TIME POLICE DISPATCHED 1:27 Pry TIME POLICE ARRIVED',4:Y7 Pry
PART I PAGE IT]OF 4]
SUPPLEMENTAL REPORT NO. EE550268
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 24-1447
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR
PEDAL-
5 ❑ AL � PROPERTY � YD OLDMET PHONE# 3 VEHICLE CYCL PEDESTRIAN OW G
4 29
LAST NAME JAROSS FIRST NAME ANGELA MIDDLE 1C
INITIAL
STREET 30
NEW AnDRFrtP 18856 COLWOOD AVE NE CITY POULSBO ST WA Z1P 983704555
6
CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED 1 31
INTERLOCK YEs No zERLOCK YES[:]NO[:]
YEs N
DRIVER'S
LICENSE STATE I WA SEX F MMDDYYv 05 TO]
- 1986
7
ON DUTY STATUS AIRBAG 2 RESTR. 9 EJECT 9 HELMET 9 INJURY 0 NATURE OF INJURIES
USE class
8 ❑ 1 32
LICENSE I CKG5708 [TAT WA VIN# 5XYP3DHC3NG204658
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 0 0 VEH.YEAR2022 MAKE KIA MODELTELLURI STYLE I VEHICLE TOWS E T SABLIN TOWED BY anvi vEH1I' FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFOANGELA JAROSS 18856 COLWOOD AVE NE POULS80 WA 983704555 m 33
12 � SHADE IN DAMAGED AREA
7 j FROM TO
LIABILITY INSURANCE INSURANCE CO STATE FARM 4449742 A2147A q"i"Olx
IN EFFECT &POLICY#
EHICLE o BarroM 34
13 LEGALLY YES N001
CITATION# CHARGE
STANDING �} 8 7
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15F� I LAST NAME FIRST NAME INIMIDDLETIAL ❑ 36
STRE
16 NEW ETETnnR"� CITY ST ZIP
CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED
NTERLOCK YES No NTERLOCK YEs NO YES NO El
17 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE (CLASS
19 ❑ 39
LICENSE rnr VIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED 3 4 4 AREA F 43
z
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LeGALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.CATALAN 02-09-24 04:41 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 ORID# 12007 O#IL WA0171300 JACOBS 2113/2024 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. EE50268 CASE# ' 24-1447 DATE AND TIME 02/09/24 13:27
OF COLLISION
UNIT 2
UNIT NTS
ml
PAGE 4 OF 4