HomeMy WebLinkAbout25-80300 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 25-80300 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I 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
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 12 - 01 - 2025 1834 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
UNION AVE NE BLOCK NO. e✓ 1200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 12TH ST NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2064196354 0 4 30
6� LAST NAME KING FIRSTNAME DEBORAH MIDDLE B 1 1 2 31
INITIAL
STREET ❑ 201 UNION AVE SE UNIT 84 CITy RENTON ST WA 2jp, 980595179 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI aT�S1t AQt5178 sTArI WAurN#' JTJHF10U130300240
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 ] 34
13 2 2003 LEXS RX P4 DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO DEBORAH KING.1 UNIONAVE SE UNIT84 RENTON WA 98059 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 4
14 LIABILITY INSURANCE STATE FARM 1367119DI247A
LI EFFECT I SUR N# TOPVE"'CLE CHARGE <1�3
OTTOM 5 36
LEGALLY YES❑NO❑ CITATION# 5
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066939934
16 a
LAST NAME BICKNELL FIRST NAME SARAH MIDDLE K
INITIAL
17❑ NEW STREETR 15531 S
7 E 184TH ST CITY RENTON ST WA ZIP 980589680 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑LICENSE I 21❑ PLA E# CHP9135 TArE WA VIN# JT8 41
BF28G9Y5080769 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2000 MAKE LEXS MODEL ES 250 STYLE SO VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO SARAH BICKNELL 15531 SE 184TH ST RENTON WA 980589680 D:2066939934 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU PORGY#ECO STATE FARM 5439323BO747IN 1 9TOP
VEHICLE ❑ ,.I—I CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES N
$ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
MAR/A FERNANDES 12848 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG57692
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80300
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 FIRST 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'
Driver 2 was driving northbound on Union Ave NE in the 1200 block. She stopped to turn left (west)
onto NE 12TH ST. While Driver 2 was waiting to complete her turn, Driver 1 rear-ended her. Driver 1
was driving northbound on Union Ave NE in the 1200 block behind Driver 2, and struck the rear
bumper of Vehicle 2 with her front bumper. The collision caused damage to the front bumper of
Vehicle 1, and damage to the rear bumper of Vehicle 2. Both parties were uninjured. Neither car was
driveable, and both were towed by Bankers Towing. I provided an exhange of information.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
MAR/A FERNANDES 12-05-25 11:19 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
M.BRAUN 2194 1 1211112025 1:36:55 PM
BADGE OR ID# ` 12848 OR]# WA0171300 TIME POLICE DISPATCHED' 6:34 PM TIME POLICE ARRIVED',6:44 PM
PART I PAGE IT]OF 3�
REPORT NO. EG57692 CASE# ' 25-80300 DATE AND TIME 12/01/25 18:34
OF COLLISION
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