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HomeMy WebLinkAbout2024-00056875 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III (III (IIIIII II II 11111111111111H11 1011111111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553961 u, 2 U210 1 1 1 U116 U214 U, 1 U2 1 U, 1 U2 1 5 9 U, 1 u221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00056875 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 S STATE ST ® ❑ Elgin RELATED ❑Y coN 09 07 2024 01:52 ®AM ❑YES ®No U1 •< PRIVATE mo /day I yr ID PM FLOW CONDITION m Eg:1604 'COUNTY PROPERTY El Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 N /MI N E S W Dana Dr 'WITH VEHICLES INVLD El STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 I&ORNER ❑ PARKED ❑ORNERLESS ❑ MD ❑PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 0 7 /1 9 8 4 FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) ,A. mo day yr General Motor'>�L�mnp 2021 00-NONE 11 1z , DUE TO CRASH El ,3-UNDERCARRIAGE 101 I 2 FIRE ❑ ISI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 2 m 1103 SU N NYDALE BLVD F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH ❑ El 1 0 1GKS2DKLOMR177462 NIA El ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same NIA 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU 5 ❑Y ®N 2 G1 ❑ORIVER ® PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NUM ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s Ford Explorer 2015 00-NONE 1t. I'_t DUE TO CRASH ❑ ® 6 , NAME(LAST,FIRST,M) mo day yr 10 ©i; 2 FIRE ❑ ® U2 C c ,3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN S 4 •Distraction Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® to H FIRST CONTACT 12 7. —6 • •5 Ifves,See Sidebar C MP11712 IL 2025 ri 0 n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FM5K8AR8FGA41631 Charter Oak Fire Insuranc ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Elgin Police ❑epartm, Elgin 8109160P901 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 997 < RESPONDER 151 , [LOIN , IL,60120 (847)289-2500 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m / / - '#OCCS > / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur CI Y U2 Z N ® 18 1 09/07 /2024 01 52 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 El 08 28 ! I 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 Ei AM ❑Maintenance U2 • ARREST NAME Osorio,Sally,A. 11-601 751557 / / Cl Pm SLMT c U 1 ® 11 1 ®CITATIONS ISSUED 0 PENDING ROAD CLEARANCE TIME 0 Utility o NSECTION CITATION NO. AM 35 2 0 ARREST NAME OSOrIo,Sally,A. 11-1303 751556 09/07 /2024 02 18 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ®AM Workers present? ❑Y 30 498-Johnson,Andrew 701 — 10 107/2024 09 00 p PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . } A CMV is defined as any motor vehicle used to transport passengers or property and. Z "--r----, , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- •t L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi Hated to trans rt between 9 and 15 assen ers including the dr ver, 9 Po P 9 N for direct compensation(example.large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP n , , MOTOR CARR ID ❑ Interstate ElIntrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, i r - DO ILCC NO. m U N XI , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Black BlackEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO: Redmons 1 Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 0 TOWED BYJTO. DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE