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Home My WebLink About23-3096 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c COLLISION REP FIT 1591971 CASE 23-3096 z INTERSTATE ❑ CITY STREET FIRE ❑RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 1 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 03 STRUCK RESERVATION z 3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑ cowsloN 03 - 1-- 2023 0630 17 ❑.= S 8 IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ JERICHO AVE NE BLOCK M300 ❑4a MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 90 00 FEET e S B W e NE 4TH ST OF1 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE. El ✓NO D:4253066826 0 81 30 6 LAST NAME GUMMERE FIRSTNAME KEVIN MIDDLE R 1 1 2 31 INITIAL STREET ❑, 14420 142ND PL SE CITY RENTON ST WA ZIP 980595538 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNIT{ON PRESENT MEDICAL TRANSPORTED 3 iNTERLOCKYEs NO INTERLOCKYEs NO vEs No�/ 8❑ DRIVERS # STATE WA SEX'M I ELMMDDYY' 11 — 27 — 1962 1 2 32 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USE CLASS 2 CLASS 1 NATURE OF INJURIES z❑ 3 LICENSE C79839W sTATe WA vIN# 1C6RR7GT3DS609381 10❑ PI ATE 14 TRAILER STATE TRAILER STATE 11 3 5 PLATE# PLATE# FROM TO TRLR. TRLR. 5 1 33 12 0 0 VIN#' VIN# >; FROM TO VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO J 9 34 13 2 2013 RAM 1500 YES[:] NO✓ REGISTERED OWNER INFO KEVIN GUMMERE 14421142ND PL SE RENTONWA 98059 VEHICLE NO. 1 ❑ SHADE IN DAMAGED AREA 35 14 LIABILI INSURANCE INSURANCE CO STATEFARM 451 5927-E26.47C 3 4 IN EFFECT &POLICY# 9TOP CITATION# CHARGE 5 36 15❑ vEEGHrACLLLEY YES❑NO❑ INATTENTIVE DRIVING STANDING 8 7 6 MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE UN�T 0' ❑✓ ❑ PEDESTRIAN ❑ ❑OWNER YES NO D:2067477976 VEHICLE CYCLE PROPS 16 a LAST NAME JAFFE FIRST NAME LISA MIDDLE I D INITIAL 17❑ STREET ❑', 22412 127TH AVE SE CITY KENT ST WA ZIP 980313961 37 NEW ADDRESS ❑ 18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED 38 INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NOF,/ 19 LDIIVERI # STATE WA ]SEX IF M .C.B. 05 _ 21 1976 39 HELMET {NJURY 1 NATURE OF INJURIES 40 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑ 21❑ LICENSE I CEW3848 TATe WA VIN# 3W2X7823NM072280 ❑ 41 PLATE# 42 22❑ PLATE# STATE PLATE# STATE 23❑ UIN#. 43 TRLR RLR 'IN#. VEH YEAR 2022 MAKE VOLK MODEL TAOS STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44 L4❑ DAMAGE YES NO YES NO REGISTERED OWNER INFO LISA JAFFE 22412127TH AVE SE KENTWA98031 VEHICLE NO.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE &POLICY#E CO SAFECO H2391853IN VEHICLE CITATION# CHARGE <E�� LEGALLY YES[Z N� 25❑ JAGENCY s a OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 26 K.LANE 10008 WA0171300 PART A PAGE 01 OF C7 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. ED43178 COLLISION REPORT III III III III III 111 1591972 CASE# 23-3096 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' Unit 3 was stopped on northbound Jericho AVE NE in a line of traffic back from the red light at NE 4th ST. Unit 2 was stopped directly behind Unit 3. Unit 1 was approaching NE 4th ST and this line of stop traffic, northbound on Jericho AVE NE. Driver 1 states he wasn't paying attention and did not realize the line of traffic was stopped and was unable to stop in time. The front end of Unit 1 struck the rear end of Unit 2. The force of this collision sent Unit 2 forward and the front end of Unit 2 struck the rear end of Unit 3. Unit 1 sustained moderate/heavy front end damage. Unit 2 sustained moderate/heavy rear end damage and minor front end damage. Unit 3 sustained minor rear end damage. Driver 1 was cited for Inattentive Driving by not driving with due care and caution to realize traffic was stopped in front of him which was the proximate cause of the collision. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. K.LANE 03-16-23 09:25 AM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY E DAT CO.JOHNSON 0505 311712023 9:58:45 AM BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 6:32 AM TIME POLICE ARRIVED 6:42 AM PART I PAGE IT]OF 4� SUPPLEMENTAL REPORT NO. ED431 78 r`) POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 23-3096 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY ;TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER L ADDRESS ` CITY ST ZIP—1 I ' 4 ❑ NAME # PLACARD: :❑ GI PLACARD IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# 3 VEHICLE tSJ CYCLE I_) PEDESTRIAN OWNER YES NO D:2063938848 0 8 29 LAST NAME DAO FIRST NAME LONG MIDDLE H INITIAL STREET 30 NEW AnDRFSP' 5301 NE 2ND CT CITY RENTON ST WA ZIP 980595190 6 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED 1 1 2 31 INTERLOCK YEs No NTERLOCK YES[:]NO[:] YEs N DRIVER'S LICENSE STATE I WA SEX M MMDDYYv 05 - 15 - 1966 7 ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES USE CLASS 8 ❑ 1 32 LICENSE D40704A [TAT WA VIN# 1FTFW1E83NFB10638 PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 0 0 VEH.YEAR2022 MAKE FORD MODELF150 STYLE VEHICLE TOWS E T SABLIN TOWED BY anvi vFH1Ci P FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFOLONG DAO 5301 NE 2ND CT RENTON WA 98059 J 9 33 12 � SHADE IN DAMAGED AREA 3 4 FROM TO ((ABILITY INSURANCE INSURANCE CO STATE FARM 5200181-A15.47 gTOp IN EFFECT &POLICY# 1 VEHICLE 34 13 2 Lecnuv YES NO❑ CITATION# CHARGE 10 BOTTUM STANDING } 8 7 6 14 ❑ UNIT Tr Vd 1RE O CYDCLE 1:1OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE INITIAL TIAL ❑ ET 16 STRETRE "F ' CITY ST ZIP NEW CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED NTERLOCK YES No NTERLOCK YEs NO YEs NO El 17 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE (CLASS 19 ❑ 39 LICENSE rnr VIN# PLATE# 20 ❑ TRAILER' TRAILER El40 PLATE#< STATE PLATE# STATE 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43 3 4 71 LIABILITY INSURANCE INSURANCE CO ' VINE EFFECT &POLICY# i 970P - 4 E:l 44 24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM LECALLv STANDING 8 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. K.LANE 03-16-23 09:25 AM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED APPROVED BY DATE 26 ORID# 10008 O#IL WA0171300 JOHNSON 311712023 PAGE F OF 4 3000-345-013(R 11118) REPORT NO. ED43178 CASE# 23-3096 DATE AND TIME 03/16/23 06:30 OF COLLISION .wx NE 4th ST N ***RIOT TO SCALE- L IT x O D IT z IT PAGE 4 OF 4