HomeMy WebLinkAbout24-9669 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE 24-ssss 2
RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY ❑ INVOLVED
2 3 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 O9 - 1-- 2024 1600 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY
BLOCK NO. e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e I405 NB ON RAMP
0 1 29
UNIT 01 VEHICLE
MOTPI PEDAL-ORCYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 8 30
6❑ LAST NAME AWKE FIRSTNAME MOHAMED MIDDLE A 1 2 31
INITIAL
STREET ❑, 1201 SUMMIT AVE APT K CITY SEATTLE ST WA ZIP 98101 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs No✓ INTERLOCKYEs NO✓ YES R No
8❑ LICENS
DRIVER # STATE WA SEX'M MMDDYY 01 — 01 — 1985 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 ATE 14 NONE sTAT SD VN# JT2EL55D755D750061203
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
rRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE J 9 34
13 3 1995 TOYT TERCEL SD DAMAGE vEs 0NO f �AWkkRS vEs❑ No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 UABILI V INSURANCE INSURANCE CO PROGRESSIVE 985837947 4
IN EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
UNIT U2 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNERMOTR PEDAL- P PERTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME MILLER FIRST NAME JEFFREY MIDDLE W
INITIAL
17 STREET❑ NEW ADOREs7 26305 230TH CT SE CITY MAPLE VALLEY ST WA ZIP 98038 4] 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs❑NOF YEs❑NOF,/
19 DRIVE # STATE SEX U M D.O.B.
10 _ 04 _ 1988 39
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 INJURY1 NATURE OF INJURIES 40
❑21❑ PLATE# D303746 rare 41
WA VIN# 1FTFWICVSAF644745 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2010 MAKE FORD MODEL F150 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO JEFFREY MILLER 26305230TH CT SE MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO USAA 008946360JIN IU
9TOP
'E""LE CITATION# CHARGE o BOTTOMLEGALYYES Nu25❑ J
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
E.EDMUNDS 12576 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF15059
COLLISION REPORT III III III III III 111
1591972 CASE# 24-9669
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MILLER R/ZALINA S
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
26305 230TH CT SE MAPLE VALLEY WA 980384718 SEXi F MMDDYyry 12 - 30 - 1991
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 2 POS. 3 2 4 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) MILLER LUCAS
ADDRESS&PHONE# D O B
MAPLE VALLEY SEX I M MMDDvvVv 07 _ 24 _ 2023
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS❑ UNIT# 2 POS 7 AIRBAG 2 RESTR. 11 EJECT 1 USE 1 2 CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) MILLER WILLIAM
AppREss&PHONE# MAPLE VALLEY U I. 07 09 _ 2020
SEX. D.O.B. _
MDDYYYY
PASSENGER WITNESS UNIT# ! 2 SEAT g AIRBAG 2 RESTR. 10 EJECT 1 HELMET 2 NJURY 1 NATURE OF INJURIES
❑ POS. USE CLASS ��— ----�
NARRATIVE'
Unit 2 was stopped at a red light on eastbound Maple Valley Highway in the left turn near the on ramp
to 1405 North. Unit 1 was traveling
eastbound on Maple Valley Highway approaching Unit 2 at this red light. Driver 1 stated he tried to
stop could
not stop in time. The front end of Unit 1 struck the rear end of Unit 2 causing damage to both vehicles.
No one in either vehicle required medical attention at the scene.
Both driver's provided valid driver's licenses, registration information, and proof of insurance.
Driver 1 was warned for not driving with due care and caution to realize that traffic was stopped in
front of him which was the
proximate cause of the collision.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by E. Edmunds/#12576 at 1918 hours on 09/14/2024, in the City of Renton, WA.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.EDMUNDS 09-14-24 05:57 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 9/14/2024 7:26:15 PM
BADGE OR ID# 12576 OR]#' ' WA0171300 TIME POLICE DISPATCHED 4:00 PM TIME POLICE ARRIVED]4:00 PM
PART Ei PAGE 2�OF❑
REPORT NO.! EF15059 CASE# ' 24-9669 DATE AND TIME 09/14/24 16:00
OF COLLISION
m,
PAGE 3 OF 3
