HomeMy WebLinkAbout25-80775 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 25-80775 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 ❑STATE ROUTE OTHER STOLEN❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY ❑ INVOLVED
2 2$
TOTAL#OF OBJECT 5
RESERVATION 1
TRIBAL UNITS 02 STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 12 - 17 - 2025 0235 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HIGHWAY
BLOCK NO. e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 ❑ FEET e S ❑ W e 140THWAYSE
❑
0 8 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2533850188 0 11
30
6❑ LAST NAME MILLER FIRSTNAME JIMMY MIDDLE G 1 1 2 31
INITIAL
STREET ❑, 3031 NE 137TH ST APT 318 CITY SEATTLE ST WA 2jp, 98125 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCK YES NO�/ YES R NO
8❑ LDRIVER # STATE WA SEX'M MID
-O B 04 1— 12 — 1985 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ Pi aT�S� CBV5253 sTArr WAVIN# 1GNFK13008J158549
TRAILER STATE TRAILER STATE
11 5 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 9 9 33
12 5 0 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 3 7 34
13 4 2008 CHEV TAHOE UT DAMAGE YES NO �MEYERS YES❑ No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 979140317
IN EFFECT &POLICY# 9TOP
vEcnLLv HicLE 5 36
res Z NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LE STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:4257616050
16 2
LAST NAME VANBUSKIRK FIRST NAME KARI MIDDLE N
INITIAL
17 STREET NEW ADDREs7 33515 DOUGLAS AVE SE CITY BLACK DIAMOND ST WA ZIP 98010 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NO� INTERLOCK YEs❑NOF YES
❑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# CBV5253 TArE WA VIN# 41
JTEAAAAH5MJ079740 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2021 MAKE 7'Dy7' MODEL VENZA STYLE (/T —FEHICLE
TOWED✓ NOO BLIN GENE MEYERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO HARTFORD 55PHG582050IN STOP 5
C(:
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
E.EDMUNDS 12576 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG60914
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80775
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'
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.
E.EDMUNDS 12-17-25 03:43 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
M.BRAUN 2194 12/19/2025 10:25:49 PM
BADGE OR ID# ` 12576 ORI#' WA0171300 TIME POLICE DISPATCHED 2:35 AM TIME POLICE ARRIVED i 2:35 AM
PART I PAGE IT]OF 4�
REPORT NO. EG60914 CASE# 25-80775 OF COLLISION
12/17/25 02:35
OF CbLLI510N
NARRATIVE
Unit 1 was stopped at a red light on westbound Maple Valley Highway in the center lane at the
intersection wih 140th WAY SE. Unit 2 was also traveling westbound on Maple Valley Highway
approaching Unit 1 and this red light in the right lane.
Power had gone out in the area moments before and was intermittently coming back on line.
Streetlights in the intersection and surrounding area were intermittenly powering on and off.
Driver 1 stated he was about to enter the intersection on a green light when he observed something
in the roadway. A separate collision had occured a few minutes prior and the debris had not been
fully removed from the roadway. Driver 1 stated he braked suddenly and did not know how the
collision occured.
Driver 2 stated she was approaching the intersection and did recall anything further. She did not know
how the collision occured.
Firefighters responded to the scene and evaluated all involved parties. No one required immediate
transportation to the hospital.
Both driver's provided a WA DL, vehicle registration, and proof of insurance. I provided an exchange
of information to both parties. Gene Meyers towing responded to the scene and removed both
vehicles. Damage appeared to exceed $1000 for both vehicles.
I certify (declare) under penalty of perjury under the laws of the State Of Washington that the
foregoing is true and correct.
Electronically Signed By E. Edmunds #12576 at 0327 on 12/17/2025 in Renton, WA.
PAGE 3 OF 4
REPORT NO. EG60914 CASE# 25-80775 DATE AND TIME 12/17/25 02:35
OF COLLISION
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