HomeMy WebLinkAbout24-11181 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-11181 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL CODING
3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN ✓ CITY# ❑
COLLISION 10 - 1-- 2024 0744 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BENSON RD S BLOCK NO. e✓ 700
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 1.❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064121316 0 11
30
6� LAST NAME GIBSON FIRSTNAME TIANA MIDDLE S 1 2 31
INITIAL
STREET ❑ 2817 NE 7TH ST CITY RENTON ST WA ZIP 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs No✓ INTERLOCKYEs NO✓ YES R No
8❑ DRIVERS
E#
ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 I I [NATURE OF INJURIES
H U SE CLASS 6 CUT ON FACE AND LEG z❑
3
10 9❑ pl ATE 14 BPW8481 STATE WA VIN# 2CKDL63FX66062249
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 3 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 5 1 34
13 2 2006 PONT TORREN UT DAMAGE vEs 0 NO agW�MEYER TOWING ves❑ No✓
REGISTERED OWNER INFO TIANA GIBSON 2817 NE 7TH ST RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14� LIABILITY INSURANCE INSURANCE CO STATE FARM INSURANCE 223.2734-A2947A 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STAIN.D'ING 7 6
UNIT a2 VE ICCMOTOLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME KELLY FIRST NAME COLLEEN MIDDLE M
INITIAL
17 STREET I❑ s❑' 17404 119TH LN SE APT H5 CITY RENTON ST WA ZIP 980586062 4❑ 37
NEW ADDREs
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICALt-T�RANSPORTED � 38
INTERLOCK YES - NO INTERLOCK YEs❑NOF YES 11 l NO❑
19 DRIVER'S STATE WA ]SEX IF I D.C.B. O6 _ 12 _ 1979 39
LICENSE# MMDDYY
[NATURE OF INJURIES
H U EET LASSY SORE CHEST AND LEFT SIDE ❑ 40
20 ON DUTY STATUS AIRBAG 6 RESTR y EJECT 1 6
❑ILICENSE 21❑ PLA E# BVM5692 TATe 41
WA VIN# 3CZRU6H33JM727459 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2018 MAKE HOND MODEL HR-V STYLE HB VEHICLE TOWED TO BLIN TOWEDBv GOV HI 44
24 DAMAGE YES✓ NO GENE MEYER TOWING YES NO✓
REGISTERED OWNER INFO COLLEEN KELLY 2307 NE 4TH STAPT D203 RENTONWA98056 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE to BOTTOM
LEGALLY YES N
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF30792
COLLISION REPORT III III III III III 111
1591972 CASE# 24-11181
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) GIBSON CAMDON
(LAST FIRST,
ADDRESS&PHONE#
2817 NE 7TH ST RENTON WA 98056 SEX M MMDDYyry 04 - 11 - 2019
{� SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER ZWITNESS[] UNIT# 1 POS. y AIRBAG 6 RESTR. 10 EJECT 1 USE CLASS 6 CUT ON HEAD
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
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.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Vehicle #1 was traveling southbound in the 700 block of Benson Rd S. Vehicle #2 was traveling
northbound in the 700 block of Benson Rd S. The driver of vehicle #1 stated she was traveling at
approximately 45mph in this 35mph zone, and her vehicle started to slide on the wet blacktop. She
was unable to maintain control of her vehicle as it slid into the northbound lane, causing the front of
her vehicle to collide with the front of vehicle #2. 1 checked the tread depth on the tires of vehicle #1
and there was sufficient tread on the tires. The driver of vehicle #2 was transported to the hospital for
chest and left side pain.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 10-29-24 01:36 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 111112024 3:53:30 AM
BADGE OR ID# 11631 OR]# WA0171300 TIME POLICE DISPATCHED; 7:46 AM TIME POLICE ARRIVED 7:49 AM
PART I PAGE IT]OF 3�
REPORT NO. EF30792 CASE# 24-11181 DATE AND TIME 10/28/24 07:44
OF COLLISION
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