HomeMy WebLinkAbout25-4913 iiTFiNII IIIII III IIIII II IIII IIIII I . 27c REPORT NO EGO1268oc� RA
COLLISION REPORT 1591971
CASE# 25-4913 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL AGENCY 4200 3
COUNTY RD NVOLVED CODING
PRIVATE WAY
2❑ TRIBAL TOTAL 1
UNITS#OF 02 SO BJECT TRUCK 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
coulsloN' 06 - 06 - 2025 1016 17 =.= S 8 W e IN OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION �✓ NON INTERSECTION ❑
SE 175TH ST BLOCK NO. e 11900 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 �. FEET S 8 W e 119TH ST SE
0 4 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:4255248118 0 1 30
5 LAST NAME HOLMAN FIRST NAME HOLLIE MIDDLE A 1 1 2 31
INITIAL
STREET ❑ 11908 SE 175TH ST G202 CITY RENTON ST WA ZIP 98057 2
NEW ADDRESS
7 CDL IGN ✓ITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 3
INTERLOCKYEs NO INTERLOCKYEs NO✓ YES NO✓
8 DRIVER'S
# STATE WA SEX F MMorYY' 10 — 21 — 1992 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET 2 1 INJURY
CLASS 1 NAruRE of INJURIES 2
LICENSE, CPL1975 STATE WA VN# 1FMCU9DG9BKC38106 3
10 PI ATP tt
11[-j— TRAILER STATE TRAILER ,STATE
11 2 5 PLATE# PLATE# FROM TO
rRLR TRLR 5 7 33
12 2 5 VIN# VIN#
( FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE
13 4 2011 FORD ESCAPE P4 DAMAGE YES NO ✓ YEs❑ No✓ 3 7 34
REGISTERED OWNER INFO OWNEDIRYDRIVER VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE❑ NSURANCE CO 1�973 4
IN EFFECT &POLICY# 11 4TOP _
Lrg LNG ❑ ❑ 5A0563846 CHARGE FAIL YIELD LEFT TURN MOTOR B 10 ooTro�m z 36
Yes NO CITATION#
15
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
VEHICLE
UNIT 02 CYCLE OWNER Q ❑ PEDESTRIAN ❑ D:4259465467
YES✓ NO
16�
LAST NAME HASANOV FIRST NAME ROVSHAN MIDDLE'
INITIAL
STREET ❑
17 '❑ 470 2ND A VE S,APT 311 CITY KIRKLAND ST, Wq ZIP 98033 4 37
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDIGALTRANSPORTED" 38
INTERLOCKYEs No✓ INTERLOCKYEs NO✓ rEs NO
19[ DRIVER'S STATE WA SEX M D-02. 09 24 1963 39
LICENSE# MMDDYY —
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U ET 2 INJCLA ICY 1 NATURE OF INJURIES 40
21 LICENSLATE E CNR1985 TATE WA VIN# JTDKDTB39C1525448 41
22❑ PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2012 MAKE TOYT MODEL PR/US STYLE p4 VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO ROVSHAN GURBANOV8534139TN AVE NE REDMOND WA 98052 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# t w
❑ N`LJ,.I—ICITAT25 �ION
CHARGEYES
ALLY
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
WA0171300
26
D.NELSON 12421
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EGO1268
COLLISION REPORT III III III III III 111
1591972 CASE# 25-4913
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INTTIAL)
ADDRESS&PHONE#
SEX' D.O.B. — [----------�
MMDDYYYY
PASSENGER F-1 WITNESS Ej UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES--�
POS. USE CLASS
'NAME
(LAST FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — L----------�
MMDDYYYY
PASSENGER DWITNESSD UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. — L----------�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS �____ ----j
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.
D.NELSON 06-06-25 12:58 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 6/16/2025 2:15:12 PM
BADGE OR ID# 12421 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 10:25 AM TIME POLICE ARRIVED 10:43 AM
PART B 3 Do-3mx-,ao(Rtrras) PAGE 27 OF 47
REPORT NO.` EGO1268 CASE# 25-4913 O COLLI COLLISION TIME
OF 06/06/25 10:16
COLLI
NARRATIVE
25-4913 ACC
On 6/6/2025 1 was working as a uniformed patrol officer and driving a marked patrol vehicle for the
City of Renton. I was dispatched to a report of a two-vehicle collision in the intersection of SE 175th
Stand 119th PI SE Renton/King/WA.
I arrived on scene and located both involved parties. The driver of Unit 1, a black 2011 Ford Escape
WA/CPL1975, was identified by her WADL as Hollie A Holman DOB: 10/21/1992. Hollie said that she
was waiting at the intersection on 199th PI to head east on 175th and did not see the Prius. She said
that she pulled out and collided with the Prius. There was damage to her front bumper and front
passenger side quarter panel. Hollie said that she did not have any insurance on the vehicle.
I spoke with the driver of the red 2012 Toyota Prius WA/CNR1985, identified by his WADL as
Rovshan Hasanov DOB: 9/24/1963. He said that he was driving east on 175th St when the Ford
pulled out and struck him. There was damage to the driver side door and driver side rear door.
Rovshan said that this was his friend's vehicle and he did have an insurance plan that included him
although he was not able to provide any proof.
Both vehicles were drivable and neither party had complaint of any pain.
cite Hollie for RCW 46.61.185.1 Failure to Yield -Left Turn under Sector#5A0563846, this citation
should be mailed to Hollie.
I provided both parties with a case number and they advised they had already exchanged information
prior to my arrival.
Nothing further.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
D. Nelson #191 6/6/2025 Renton WA
PAGE 3 OF 4
REPORT NO. EGO1268 CASE# 25-4913 DATE AND TIME i 06/06/25 10:16
OF COLLISION
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