HomeMy WebLinkAbout25-80592 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 25-80592 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
CowsloN 12 - 10 - 2025 1754 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
DUVALL AVE NE BLOCK NO. e✓ 600 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 .❑ FEET e S ❑ W e NE 6TH ST
❑ �
1 2 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063359075 0 11
30
6� LAST NAME BELLEMERE FIRSTNAME CONNIE MIDDLE G 1 2 31
INITIAL
STREET ❑ 4827 NE 5TH ST CITY RENTON ST WA ZIP 980594850 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 6 RESTR 4 EJECT 1 I [NATURE OF
H U EET 2 1 INJURY
CLASS ju BACK PAIN JURIES z❑
3
,OF]
P1 aTS BPN0308 sTAr WA uN# 1N4AL21E67C113919
IT STATE TRAILER STATE
11 3 5 PLATE# I PLATE# I I 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 5 1 34
13 2 2007 NISS ALTIMA SD DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO CO.BELLEMERE 4827 NE STH ST RENTON WA 98059 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE USAA 005050580071019
IN EFFECT &POLICY#VEHICLE CHARGE 36
LEGALLY re6 No clTAnoN# 5A0319260 FAIL YIELD AT YIELDU�'
5
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4259023002
16 a
LAST NAME KINDRA FIRST NAME NAVEEN MIDDLE I S
INITIAL
17❑ STREET Is❑' 8819 138TH CT SE CITY' NEWCASTLE ST WA ZIP 980593496 37
NEW ADOREs
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19� DCEN6 STATE WA SEX M MMr D.O.B. 03 O6 _ 2008 39
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# AYL8990 TArE 41
WA VIN# JTHCE16L2E5020836 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2014 MAKE LEXS MODEL GS STYLE SD VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO JASBIR KINDRA 8819138TH CT SE NEWCASTLE WA 98059 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSU8 PORGY#E CO NATIONAL INS COMPANY OF AMERICA H2461992 STOP 5
IN EFFECT
VEHICLE ❑ ,.I—I CITATION# CHARGE
25 to BOTTOM
LEGALLY YES N
' a
7m-
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
FERNANDES 12848 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EG57694
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80592
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,FIRS 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'
Driver 2 was driving northbound on DUVALL AVE NE in the 600 block and Driver 1 was driving
westbound on NE 6TH ST approaching the intersection of NE 6TH ST and DUVALL AVE NE. Driver
1 failed to yield to Driver 2 before entering the intersection (from the east) in front of Driver 2. Driver 2
was unable to stop and struck the left side of Vehicle 1 with the front bumper of Vehicle 2. Both
vehicles were not driveable and were impounded. There was heavy damage to the left side of Vehicle
1 and the front bumper of Vehicle 2. Driver 1 reported minor back pain and was medically checked by
the fire department. Driver 1 was issued an infraction for failing to yield to Driver 2. 1 took photographs
of the damage.
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 12-10-25 09:23 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
M.BRAUN 2194 1 1211112025 1:27:46 PM
BADGE OR ID# ` 12848 OR]#' WA0171300 TIME POLICE DISPATCHED 5:55 PM TIME POLICE ARRIVED',5:59 PM
PART I PAGE IT]OF 3�
REPORT NO. EG57694 CASE# ' 25-80592 DATE AND TIME 12/10/25 17:54
OF COLLISION
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