HomeMy WebLinkAbout23-4636 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-4636 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4100 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#
cowsloN 04 - 1-- 2023 1406 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SE PETROVITSKY RD BLOCK NO. e✓ 11100 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e 111THAVE SE
0 4 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
No ,/ D:2069793585 0 11
30
6� LAST NAME LAM FIRSTNAME KIM MIDDLE N 1 1 2 31
INITIAL
STREET ❑1 1620 BENSON RD S#217 CITY RENTON ST WA 21p 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES �No /
LRIIVER # STATE WA SEX'F MM D Y' 08
8❑ — 04 — 1989 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATFBit BWP3807 sTArI WA urN#' JTHG81F25L5042952
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR $ 7 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34
13 2 2020 LEXS IS SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO KIM LAM 1620 BENSONRD S#217 RENTON WA 98056 D:2069793585 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAFECO H2420084 3 4
IN EFFECT &POLICY# 9TOP
VE—L' CHARGE 1 5 36
LEGALLY YES No CITATION# 3A0371865,3A0371865 FAIL YIELD AT YIELD 10 Borrom
15❑ STANDING 8 7 6
MOTOR PEDAL- ❑ ❑:. PEDESTRIAN PROPERTY DAM THR PHONE
UNIT 02 V� IEHIC OLD MET LE ❑ CYCLE OWNER ❑ YES,/ NO D:2069475229
16 a
LAST NAME NELSON FIRST NAME DANE MIDDLE ,/
INITIAL
17❑ STREET ❑', 17520 157TH PL SE CITY RENTON ST WA ZIP 98058 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs I'✓ No❑
19 DRIVER #
I INJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG, 1 RESTR 13 EJECT 3 USE 5 CLASS LEG AND SIDE PAIN
21❑ LICENSE 15.18731 TAre WA vIN1 1HD1LF318GC416078
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
TOWED eY Gov HI 44
VEH YEAR 2016 MAKE Hp MODEL XL1200 STYLE MT DAMAGE TOWED✓ NOO BLIN BANKERS YES No,/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO UNKNOWN
IN EFFECT &POLICY# I 9TOP 5
VEHICLE YES[:] N([:] CITATION# 3A0371866 CHARGE NO MOTORCYCLE ENDORSEMENT ,oBOTTOM
25
LEGALLY
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED55405
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4636
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) CRAIG ORION D
(I.P.ST FIRST,
ADDRESS&PHONE# D O.B. '
9014 E MAIN ST C118 BONNEY LAKE WA 98391 2532308795 SEX M MMDDYyry 11 - 27 - 1963
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL) CRAIG SHANE M
ADDRESS&PHONE# D O B
17341 121ST LN SE#Z301 RENTON WA 98056 2533536819 SEX M MMnDuvvv 01 _ 08 _ 1992
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR, EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 (a motorcycle) was traveling eastbound on SE Petrovitsky RD in the right of two eastbound
lanes approaching 111th AVE SE. Unit 1 was stopped at a stop sign on northbound 111th AVE SE at
SE Petrovitsky RD to turn left onto westbound SE Petrovitsky RD. Driver 1 said there was a vehicle
in the center turn lane and the two exchanged waves to give the other a signal to go first as they
needed to occupy the same area. Driver 1 states that once this interaction was complete, she
proceeded to turn left unknowingly turning out directly in front of Unit 2. Unit 2 was forced to brake
heavily in order to avoid the collision causing the motorcycle to skid and lose control falling to its side
throwing the rider (Driver 2) off of the bike. Unit 2 and Driver 2 slid on the ground before coming to
rest on the south curb. Unit 1 was not struck during the collision.
Driver 1 was cited for failure to yield at an intersection by proceeding from the stop sign onto SE
Petrovitsky RD failing to yield the right of way to Unit 2, which had the right of way, which was the
proximate cause of the collision as Unit 2 had to perform evasive action resulting in 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 04-26-23 02:38 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 412812023 3:01:52 PM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 2:07 PM TIME POLICE ARRIVED 2:10 PM
PART I PAGE 2�OF❑
REPORT NO. EU55405 CASE# 23-4636 DATE AND TIME 04/25/2314:08
OF COLLISION
lth AVE SE
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***NOT TO SCA m