HomeMy WebLinkAbout25-9533 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 25-9533 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT 8 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#
cowsloN 11 - 1-- 2025 1212 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
NE 4TH ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e DUVAL!AVE NE
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063355342 0 11
30
LAST NAME HERNANDEZ ESTRADA FIRST NAME JOSE MIDDLE L
6 INITIAL 1 2 31
STREET ❑ 11020 SE KENT KANGLEY RD APT CITY KENT ST WA 2jp, 980307251 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
LICENSE CMJ6241 sTArI WAurN# 3N6CMOKN9EK697319
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#'
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7
13 34
4 D OW NISS NV200 DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFOARMADILLO PAINTING COMPANY LL 610 INDUSTRY DR TUKWILA WA 98188 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4 LIABILITY INSURANCE INSURANCE CO 2 4
14 ❑ WESTERN MUTUAL INS.CO.CPP 1305374
IN EFFECT &POLICY# 9TOP
vewcLE CHARGE 5 36
EGHALLY YES❑NO❑ CITATION# 5AO909589 IMPROPER LANE USAGE o eorroM
15❑ STANDING 8 7 6
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
U�iT VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER ❑ YES NO ,/ D:4252138388
16 a
LAST NAME SIMDNS FIRST NAME JACQUELINE MIDDLE M
INITIAL
17❑ STREET ❑', 17509 SE 257TH ST CITY' COVINGTON ST WA ZIP 980428367 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 DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CL68314 TAre WA VINIi JM3KFBCM6R0398997
❑ 41
PLATE#
42
22❑ PLATE# STATE pLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2024 MAKE ryMAZp MODEL CX-5 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO JACQUELINE SIMONS 17509 SE 257TH ST COVINGTON WA 98042 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO PROGRESSIVE 860853571IN IUQ,
'E""LE ❑ ,J� CITATION# CHARGELEGALYYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.ARNOLD 12509 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG44868
COLLISION REPORT III III III III III 111
1591972 CASE# 25-9533
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
PM 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.
C.ARNOLD 11-03-25 02:25 PM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 11/4/2025 11:50:55 AM
BADGE OR ID# 12509 ORI# WA0171300 TIME POLICE DISPATCHED 12:13 PM TIME POLICE ARRIVED',12i18 PM
PART I PAGE IT]OF 4�
REPORT NO. EG44868 CASE# 25-9533 OF COLLISION
11/03/25 12:12
OF CbLLI510N
NARRATIVE
CC 25-9533
On 11/3/2025 at 1213 hours I was dispatched to a motor vehicle collision at Duvall Ave NE and NE
4th St in the City of Renton, King County, Washington.
Pre-Collision
Driver 2 stated that she was traveling West on NE 4th St approaching Duvall Ave NE in the #1 lane.
Driver 1 stated that he was traveling West on NE 4th St approaching Duvall Ave NE in the #2 lane.
Collision
Driver 2 stated that Unit 1 merged from the #2 lane to the #1 lane upon doing so, the rear passenger
side door of Unit 1 collided with the front passenger side bumper of Unit 2.
Driver 1 stated that he did not see Unit 2 and began to merge from the #2 lane to the #1 lane. Driver 1
stated that the rear passenger side door of Unit 1 collided with the front drivers side bumper of Unit 2.
Injuries
None reported.
Vehicle Disposition
Both vehicles were operational.
Proximate Cause
I determined that Driver 1 is the proximate cause of this collision because a vehicle shall be driven as
nearly as practicable entirely within a single lane and shall not be moved from such lane until the
driver has first ascertained that such movement can be made with safety.
Driver 1 was cited per RCW 46.61.140
1 certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer C. Arnold #12509 at 14:02 on 11/3/2025 in the City of Renton, King
County, Washington.
PAGE 3 OF 4
REPORT NO. EG44868 CASE# ' 25-9533 DATE AND TIME 11/03/25 12:12
OF COLLISION
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PAGE 4 OF 4