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HomeMy WebLinkAbout24-12010 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c COLLISION REP FIT 1591971 SASE 24-12010 z INTERSTATE ❑ CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4100 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 1 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 11 - 1-- 2024 0809 17 ❑.❑ S 8 W e IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑ SE CARR RD BLOCK NO. e✓ 10600 ❑ 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ �.❑ FEET e S ❑ W e 106TH PL SE 0 1 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El NO D:2062617065 0 11 30 6� LAST NAME XIE FIRSTNAME ZESHENG MIDDLE 1 2 31 INITIAL STREET ❑ 17718 116TH AVE SE CITY RENTON ST WA 21p 98058 z NEW ADDRESS ]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/ 8❑ LRIIVER # ON DUTY❑ STATUS AIRBAG 1 RESTR 9 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑ 3 ,OF Pi ATNES# BRH9960 sTAr WAv N# JFIZNAE16K8703550 TRAILER STATE TRAILER STATE 11 3 0 PLATE# PLATE# FROM TO TRLR. TRLR 3 7 33 12 2 5 VIN#' VIN# >; FROM TO ❑ VEH.YEAR 2019 TOYT 86 CP D MAKE MODEL STYLE VEHICLE TOWED TO BLIN T BS k GOVT.VEHICLE 5 1 13 34 4 AMAGE YES NO YES[:] ✓No REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 SHADE IN DAMAGED AREA ❑ 35 4 INSURANCE CO 4 14 IN EF IT INSURANCE STATE FARM 457334l-626.478IN EFFECT &SUR N# TOPVE"'CLE CHARGE <1�3 OTTOM 5 36 LEGALLY YES❑NO❑ CITATION# 4AO873220 FAIL TO STOP AT SIGNAL MARKING 15❑ STANDING 7 6 1,1 MOTOR PEDAL-: PROPERTY DAM THR OLD MET PHONE UNIT 02 ❑ PEDESTRIAN ❑ ❑ VEHICLE CYCLE OWNER YES�/ NO 16 a LAST NAME FERGUSON FIRST NAME SHANNON MIDDLE D INITIAL 17 STREET NEW ADOREsS❑' 21207 97TH PL S CITY KENT ST WA ZIP 98031 4❑ 37 18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38 INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/ 19 DRIVER'S STATE WA ]SEX IF D.C... 12 �_ 14 _ 1967 39 LICENSE# MMDDYY 20❑ ON DUTY STATUS AIRBAG 1 RESTR 9 EJECT 1 HELMET 2 INJURY 6 NATURE OF INJURIES ❑ 40 USE CLASS NECK AND BACK PAIN LICENSE I ❑21❑ PLA E# BDX4431 TArE WA VIN# 41 JTHKD5BH2H2286719 1 42 22❑ PLATE# STATE PLATE# STATE 23❑ VIN#. 43 TRLR RLR 'IN#. TOWED BY GOV HI 44 VEH YEAR 2017 MAKE LEXS MODEL C]-2OOl-I STYLE HB —TEHICLE TOWED✓ NOO BLIN BANKERS YES NO�/ 24❑ REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE N0.2 SHADE DAGED AREA 4 INAEFFITY ECTNSURANCE INSU&POLICY#E CO USAA I 5VEHICLELLY ❑ ,.IICITATION# CHARGE25 GQ LEGA YES N`LJ s � e 7B- S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY J 26 MIN FLICK 12825 WA0171300 PART A PAGE 01 OF C7 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. EF38000 COLLISION REPORT III III III III III 111 1591972 CASE# 24-12010 ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL) SMITH DALINE P (LAST FIRST, ADDRESS&PHONE# D O.B. 18100 SE 107TH PL#4 RENTON WA 98058 2532456978 SEX U MMDDYyry - - PASSENGER WITNESS UNIT# j SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES ❑ �' POS. USE CLASS NAME '(LAST,FIRST MIDDLE INITIAL) ADDRESS&PHONE# D O B 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.0.8.MMDD -❑ YYYY. PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES ❑ ❑ POS. USE CLASS ----� NARRATIVE' Unit 01 was driving westbound on SE Carr RD. The traffic light was out on SE Carr RD at the intersection of 106th PL SE. A witness stated that unit 01 did not stop at the intersection. Unit 01 then collided with the passenger side door of unit 02. Unit 02 had been proceeding northbound on 106th PL SE when unit 01 hit her. I determined the proximate cause of the accident was that unit 01 did not stop at the non-functioning traffic signal. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Electronically signed by B. Flick 12825 on 11-20-2024 in Renton, WA. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. BENJAMIN FLICK 11-20-24 10:44 AM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE C.JACOBS 1953 1 1112112024 10:09:34 AM BADGE OR ID# 12825 OR]#' WA0171300 TIME POLICE DISPATCHED; 8:11 AM TIME POLICE ARRIVED 8:15 AM PART I PAGE IT]OF 3� REPORT NO. EF38000 CASE# ' 24-12010 DATE AND TIME 11/20/24 08:09 OF COLLISION u {r. roro � 1 J � C 3 'l 5 �4 u } 4u�� � 35 r t h mlp r�y 13 PAGE 3 OF 3