HomeMy WebLinkAbout24-9701 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO ER STATE OF
COLLISION REPORT 1591971
CASE# 24-9701 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL A`NG 4200 3
COUNTY RD PRIVATE WAY NT&RUN CODING
LVED
2❑ TRIBAL UN TS#OF 02 -Fs 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
cDUISION' 09 - 15 - 2024 1615 17 =.= S 8 W E INOF 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
SUNSET BLVD N BLOCK NO. e 300 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 300 00 FEET e✓ S 8 W e N 3RD S
2 0 29
F
MOTtlR PEDAL- DAMAG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2534147815 0 1 30
5 LAST NAME LAVERTY FIRST NAME ANN MIDDLE M 1 2 31
INITIAL
STREET ❑ 1150 SUNSET BLVD NE APT 322 CITY RENTON ST WA ZIP 980562987 2
NEW ADDRESS
7 CDL IGNITIQN REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYES NO Z/ INTERLOCKYEs Nt �/ YES F Nor,/
8� LICIENS# STATE WA SEX F MMDpyy' 03 — 30 — 1971 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET INjURy
CLASS 1 NAruRE of INJURIES 2
LICENSE, CPG7369 STATE WA VIN# KMHGC4DDOEU265197 3
10[9� as ATP rt
11[-j- TRAILER STATE TRAILER ,STATE ROM TO
11 3 5 PLATE# PLATE#
TRLR TRLR 1 5 33
12 3 5 vIN# vIN#
( FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE
13 4 2014 HYUN GENESI SD DAMAGE YES�No ✓� Yes 1 5 34
REGISTERED OWNER INFO ANN LAVERTY 1150 SUNSET BLVD NE APT 322 RENTONWA98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 3 4
4 LIABILITY INSURANCE INSURANCE CO
14 Z SAFECO H2348218
IN EFFECT &POLICY# 4TOP
VEHICLE CHARGE 5 36
Lemur YES❑NO❑ CITATION# 7 0 80TTOM
15❑ sTnNowc s 7
III MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE OWNER YES 1/ NO D:2063000469
16�
LAST NAME WIEGERING FIRST NAME ISABEL MIDDLE I M
INITIAL
❑
17 F1 STREET' 6012 NE 2ND CT CITY RENTON ST, W 37
q ZIP 980598571
NEW ADDRESS❑
1g❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPQRTED' 38
INTERLOCKYEs Na INTERLOCK YES No ves NO
19 DRIVER'S STATE WA SERIF I D-02. 05 18 2007 39
LICENSE# MMDDYY -
HELMET INJURY' NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21 LICENSLATE E CFH8103 TATE WA 11IN# UTEBU17R038002436 41
22❑ [TILER TRAILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2QQ3 MAKE TOYT MODEL 4RUNNER STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO ..El WIEGERING 6012 NE 2ND CT RENTON WA 98059 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSURANCE CO USAA 01453984OC71020
IN EFFECT &POLICY# 9TOP
vewaE ❑ ,.I—I CITATION11 CHARGE 1060TTOM
LecnLLY YES N J
25 a e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EF16915
COLLISION REPORT III III III III III 111
1591972 CASE# 24-9701
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
NAME DAILY DANIEL J
(LAST,FIRST MIDDLE INITIAL}
ADDRESS&PHONE# D O� '.
2422 MEADOW AVE N RENTON WA 980562529 SEX' M MMDDvvvv 05 - 22 - 1992
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
�' 1 POS. 3 I2 4 1 USE CLASS ;1
'NAME
LAsr F RST,MIDDLE INITIAL) HILL KIONA C
ADDRESS&PHONE#
419 ORCAS PL NE RENTON WA 98059 SEX' F D•O
MMDD _ 18 _ 2006
YYYY
NATURE OF INJURIE
SEAT HELMET INJURY
S
PASSENGER WITNESS UNIT# 2 SEAPOS 3 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1 ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B.M F L----------�
MDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY rNATURE OF INJURIES
❑ Q' POS. GLASS — ----�
NARRATIVE
Units 1 and 2 both traveling south along the 300 block of Sunset Blvd N. Unit 1 proximate cause of
collision, with improper lane change into Unit 2 causing reportable non disabling rear driver side
damage to Unit 1 and reportable disabling front passenger side damage to Unit 2. No injuries.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 09-15-24 05:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 9/21/2024 5:44:36 AM
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 4:18 PM TIME POLICE ARRIVED 4:17 PM
PART B 3 Da-3m5-,aa(R11ras) PAGE 27 OF 37
REPORT NO.'; EF16915 CASE# 24-9701 DATE AND TIME 09/15/24 16:15
OF COLLISION
u
PAGE 3 OF 3
