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COLLISION REP FIT 1591971
CASE 24-12937 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' FENCE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
COLLISION'. 12 - 19 - 2024 0534 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE PETROVITSKY RD BLOCK NO. e✓ 11100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:5312258655 30
6� LAST NAME ANIM FIRSTNAME STEPHEN MIDDLE A 1 1 2 31
INITIAL
STREET ❑1 11100 SE PETROVITSKY RD APT K CITy RENTON ST I WA 2jp, 980555660 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� CCN0420 sTArI WAurN# KMHCT5AE6DU103025
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. RLR 1 7 33
12❑ VIN#j VIN#
FROmM TO
34
13❑ VEH.YEAR2013 MAKE HYUN MODEL ACCENT STYLE HB VEHICLE TOWED0NOOffBLIN WAWkkRSTOWING vOs❑ENo /
DAMAGE IILLJJII
REGISTERED OWNER INFO AUOUSTINE ADJ.400 TAYLOR AVE NWAPT 205 RENTON WA 98057 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO STATE FARM INSURANCE 568 5601-DO8-47 001
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LECALLv YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY ✓ DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4252764430
16❑
LAST NAME APARTMENTS FIRST NAME BENSON DOWNS MIDDLE
INITIAL
17 STREET I❑ 11100 SE PETROVITSKY RD CITY' RENTON ST WA ZIP 98055 37
NEW ADDREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t l NO❑
19 LLIICENS RIVERIS# STATE SEX U MMDDYY 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE LICENSE vIN# 41
1
PLATE#
42
22❑ PIR TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN It IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF49146
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12937
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'
The driver of vehicle #1 advised he was turning right onto SE Petrovitsky Rd out of the Benson
Downs Apartments parking lot on the north side of the road in the 11100 block of SE Petrovitsky Rd.
He stated the vehicle to his left, which was traveling westbound on SE Petrovitsky Rd, was traveling
at a high rate of speed, causing him to underestimate the amount of time it would take for this vehicle
to get to him. Due to this vehicle's high rate of speed, the driver of vehicle #1 took evasive action and
swerved to the right to avoid a collision with the other vehicle. Although the two vehicles did not
collide, this did cause vehicle #1 to collide with a fence on the north side of the road, causing damage
to several bushes, the fence, and damage to the front left, front right, right side, and rear right
portions of vehicle #1.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 12-19-24 04:40 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 1212312024 4:05:13 AM
BADGE OR ID# 11631 ORI# WA0171300 TIME POLICE DISPATCHED 5:37 AM TIME POLICE ARRIVED',5:43 AM
PART I PAGE IT]OF 3�
REPORT NO. EF49146 CASE# 24-12937 DATE AND TIME 12/19/24 05:34
OF COLLISION
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