HomeMy WebLinkAbout25-467 POLICETRAFF'c" III !�� I III I III I IIII III II I REPORT NO. EF58478 5 1 27
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE zs-467 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 01 - 1-- 2025 1505 17 ❑-= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 13100 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e 131ST ST SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:8156160407 0 7 30
6� LAST NAME BRYANT FIRSTNAME TYLER MIDDLE S 1 1 2 31
INITIAL
STREET ❑ 3153 W LIGHTSVILLE RD CITY LEAF RIVER ST IL ZIp, 61047 2
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 9 RESTR 9 EJECT 1 HELM
USEET INJUR
5Y NA
1 TURE OF INJURIES 2❑
3
10 1❑ PI ATE 14 3749695 STATE I! VIN# 3C6RR7KT2LG130818
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 2 2020 DODO RAM DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO TYLERBRYANT3153WLIGHTSWLLERD LEAF RIVER IL 61047 D:8156160407 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
vErIICLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ �STA"'
8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:4256475077
16 a
LAST NAME DEEBA FIRST NAME FAWZI MIDDLE M
INITIAL
17❑ STREET ❑', 17351 SE 187TH ST CITY' RENTON ST WA ZIP 98058 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19 D IVEW #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I C07697F TATE I WA VIN# 1FTEW1EF8FKE77697
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2015 MAKE FORD MODEL F150 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO FAWZI DEEBA 17351 SE 187TH ST RENTON WA 98058 D:4256475077 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE INSU&POLICY#E CO SAME. I GD
VE""LE CITATION# CHARGE
LEGALLY YES Nu
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF58478
COLLISION REPORT III III III III III 111
1591972 CASE# 25-467
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'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 01-15-25 10:43 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 112212025 2:11:23 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED 3:24 PM TIME POLICE ARRIVED',3:24 PM
PART I PAGE IT]OF 4]
REPORT NO. EF58478 CASE# 25-467 OF COLLISION
01/14/25 15:05
OF CbLLI510N
NARRATIVE
lane 1 eb wht/1 red/2 rear
RTF
I was Dispatched for a phone follow up reference a recent crash at the 13100 block of Maple Valley
Hwy.
I contacted the driver of unit 2 by phone that told me he was stopped for traffic eastbound lane 1 just
before the intersection, although the light had just turned green he was waiting for move when he was
hit from behind by unit 1. He said they both pulled from the roadway and stopped and made an
information exchange. Unit 2 told me he wanted a police report. He said the other driver took
responsibility for contacting him from behind. Unit 2 was worried because unit 1 did not provide proof
of insurance at the time of exchange. Unit 2 did not complain of injury and damages did not require a
tow truck.
I contacted unit 1 who confirmed his name and that he was the other driver involved. He told me he
was distracted and bumped into the back of unit 2. He said unit 2 should not worry that in fact he
does have insurance. Unit 1 told me he was going to text me a copy of his insurance which he has
not in over 19 hours at this point. Unit 1 did not complain of injury and damages did not require a tow
truck.
Information/Insurance only
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 1/15/2025
PAGE 3 OF 4
REPORT NO. EF58478 CASE# ' 25-467 DATE AND TIME 01/14/25 15:05
OF COLLISION
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PAGE 4 OF 4