HomeMy WebLinkAbout25-80247 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. EG60203 170
27
COLLISION REP FIT 1591971
CASE 25-80247 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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#
cawsloN 11 - 1-- 2025 1057 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BRONSON WAY N
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e GARDEN AVE N
1 2 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:2066832167 0 11
30
6� LAST NAME CAMERON FIRSTNAME MONA MIDDLE L 1 1 2 31
INITIAL
STREET ❑, 1713 MORRIS AVE S CITY RENTON ST WA Zjp, 980553333 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES 1/ NO
8❑ LRIIVERS STATE WA SEX'F MM DAY' 04 1- 30 - 1962 2 32
CENSE 9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 HELMETU E 2 CLASS 7 [NATURE OF RIGHTARMJURIEs z❑
3
10 9❑ p7 AT 14 AZK1796 STATE WA VIN# 3FA6POG77GR368099
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# ROM ro
TRLR. TRLR 5 3 33
12 2 5 VIN#j VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 3 ] 34
13 2016 FORD FUSION P4 DAMAGE YES NO �MEYER YES❑ No✓
REGISTERED OWNER INFO COMMUNITIES BETHESDA LUTHERAN 10930 SE 235TH PL KENT WA 98031 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILITY INSURANCE z INSURANCE CO BROWN AND BROWN INSURANCE PHPK2683431
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2064378911
16 a
LAST NAME SAMAD FIRST NAME RIZWAN MIDDLE N
INITIAL
17 STREET❑ NEW ADDRESS❑' 8311 HUNTS POINT PL CITY HUNTS POINT ST WA ZIP 980041005 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO INTERLOCK YEs I I NOF YES t l NOF,/
19 LDI IVER # STATE WA SEX M M D.C.B. 02 _ 04 1958 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
LICENSE I ❑21❑ PLA E# D29165G TATE 41
WA VIN# 1GT12SEY4KF151724 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2019 MAKE GMC MODEL SIERRA STYLE TR VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO RIZWAN SAMAD 8311 HUNTS POINT PL HUNTS POINT WA 98004 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 5748550-A22-47IN 9TOP 5
vEHICLE ❑ ,J� CITATION# CHARGE to BOTTOM
LEGALLY YES N`[J
25 e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
RAYMOND WATSON 13127 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG60203
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80247
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.
RAYMOND WATSON 12-08-25 05:58 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.TRADER 4553 12/18/2025 10:01:00 AM
BADGE OR ID# 13127 OR]# WA0171300 TIME POLICE DISPATCHED; 10:57 AM TIME POLICE ARRIVED 10:59 AM
PART I PAGE IT]OF 4�
REPORT NO. EG60203 CASE# 25-80247 OF COLLISION
11/29/25 10:57
OF CbLLI510N
NARRATIVE
25-80247
This report is a summary of events that occurred and is not an exact sequencing of events.
Statements have been paraphrased and summarized.
On 11/29/2025 at approximately 1057 hours, myself, Officer R. Watson, was dispatched to an
unknown accident, at the intersection of Bronson Way N and Garden AVE N, within the City Limits of
Renton, County of King, State of Washington.
Dispatch notes stated that there were two vehicles involved and unknown if injuries.
When I arrived on scene, I saw two vehicles with significant damage at the intersection.
Unit#1 driven by Mona L. Cameron (DOB 04/30/1962) verified by WA DOL photo, stated that she
was driving a Red 2016 Ford Fusion, WA plate AZK1796. There were no other passengers in the
vehicle. Mona said that she made a left turn and pulled onto Bronson Way N after stopping for the
stop sign on Garden AVE N. She did not see any vehicles but then collided with unit#2. Mona said
that she had right arm pain, was assessed by medics on scene and transported to Valley Medical
Center. When I asked for Mona's license, registration and insurance she was able to provide me with
all documents. Unit#1 had significant damage to the left side side of the vehicle, multiple airbag
deployment and was not able to be driven from the scene. Unit#1 was towed by Gene Meyer
Towing.
Unit#2 driven by Rizwan M. Samad (DOB 02/04/1958) verified by WA DOL photo, stated he was
driving a Blue 2019 GMC Sierra, WA plate D29165G. There were no other occupants in the vehicle.
Rizwan said that he was traveling west bound on Bronson Way N when unit#1 pulled in front of him
from Garden AVE N and he was unable to stop in time. Rizwan said he was not injured and declined
aid. Unit#2 had moderate front end damage, no airbag deployment and was able to be driven from
the scene.
An exchange of information was completed and provided to each party.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer R. Watson #13127 12/08/2025 1644 hours, Renton, King County,
WA.
PAGE 3 OF 4
REPORT NO. EG60203 CASE# ' 25-80247 DATE AND TIME 11/29/25 10:57
OF COLLISION
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