HomeMy WebLinkAbout24-12436 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 24-12436 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 ❑2$
TRIBAL UNITS 01 STRUCK' META!SIGN POST
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION'. 12 — 03 — 2024 1415 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BENSON DR S BLOCK NO. e✓ 1500 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 .❑ FEET ❑ S ❑ W❑ S PUGET DR
❑ �
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063486554 30
6� LAST NAME SMITH FIRSTNAME JEFFREY MIDDLE C 1 1 2 31
INITIAL
STREET ❑, 1425 S PUGET DR#206 CITY RENTON ST WA 2jp, 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ I INTERLOCK YES NO�/ YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
❑10❑ P1 aT�S� CES1494 sTArI WWAvrN# 5NPD84lFOJH394525 3
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. YRLR. 3 5 33
12❑ VIN#j VIN#
2018 HYUN ELANTR 4D I FROM 34
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 4 DAMAGE YES NO �/ YES[:] NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
vEHICLE CHARGE 5 36
LEGALLY YEs❑NO CITATION# W24020540 OP MOT VEH W/OUT INSURANCE )o Borro6
15❑ STANDING 8 7 6
VEHICLE CYCLE PROPOWNERTY
DYES NO OLD MET PHONE
UNIT 02 El ❑ PEDESTRIAN ❑ ❑
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
17❑ NEW ADDRESS' CITY ST ZIP ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38
iNTERLOCKYES�NOF INTERLOCK YEs❑NOF YES
❑NO❑
19 LLIICENS # STATE SEX MMDDYY —❑_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE LICENSE vIN# 41
PLATE#
42
22❑ PLATILER E# STATE pLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWEDBY Gov HI 44
L4❑ D YES NO YES NO
REGISTERED OWNER INFO AMA VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# J AGENCY
26
R.ON/SHl 5738 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF42208
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12436
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'
Unit 1 driver Jeffrey Smith told me that he was turning from westbound S Puget Dr onto southbound
Benson Dr S, when he was blinded by the sun, lost control of his car, veered off of the pavement on
the right, and struck a Metro bus stop sign and metal trash bin. Smith told me that he had no
insurance for his car. I advised Metro of the damage and the case number.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 12-03-24 03:45 PM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 12/4/2024 4:06:14 AM
BADGE OR ID# 5736 OR]# ! WA0171300 TIME POLICE DISPATCHED 2:21 Pry] TIME POLICE ARRIVED:2:21 PM
PART I PAGE IT]OF 3�
REPORT NO. EF42208 CASE# ' 24-12436 DATE AND TIME 12/03/24 14:15
OF COLLISION
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