Loading...
HomeMy WebLinkAbout2024-00057438 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II DIII 111111 ll 11111111111111H11 101111111111110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003553546 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00057438 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 S RANDALL RD ® ❑ Elgin RELATED ❑Y CON 09 09 2024 12_38 EH,'" ❑YES ®NO U1 • •< PRIVATE mo /day I yr ®PM FLOW CONDITION m qQ(y�/MI N O E S W S artan ❑r 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ER SLOW 1 N 129- ICJ P 'WITH VEHICLES INVLD ❑ STOPPED U2 —I AT INTERSECTION WITH INANE OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N [] FREE FLOW # LNS ' O tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 0 4 /1 9 8 7 FOR DAMAGED AREA(S) FecNt TOWED U1 ,Amanda. M. Chevrolet Tahoe 2010 00-NONE „ , DUE TO CRASH p 21 NAME(LAST,FIRST,M) mo day yr -4 13-UNDERCARRIAGE I,• FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D 2 DISTRACTED 0 lid U2 2 m 8N689 BURLINGTON RD F SY15-OTHER ❑Y ®N SE❑UNK VEH. n AT CRASH M IN ENGAGEDO 99-UNKNOWN 9 16-TOP 3 •Distraction Value ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 8 i1 6 ii 4 COM VEH 0 ® 1 0 1 G N MCAEO7AR244952 American Alliance ❑Y ®N U2 IR RI in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same ILAA085079801 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU 5 ❑Y ®N 2 0 s ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,MI Hunter,Quantice. N. 0 3o 2 y 1 yr 9 9 5 Nissan Sentra 2017 DO-NONE ;0 12 s FIREETocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) • DISTRACTED ❑ IN SPDR 0 a` 1366 SAN DH U RST LN M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ) ' 4 COM VEH ❑ ® U1 FIRST CONTACT 6 7__•-_1 ;_5 •IrYes,See SidebarC Z SOUTH E LG I N IL 60177 0 EC97427 IL 2024 F 0 ((I D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)501-2817 H536-7149-5091 IL D 0 3N1AB7AP6HY385040 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Bangiorno. Pamela.J. 811119076 BAG ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 221 RIVER HAVEN DR. EAST DUNDEE. IL.60118 (224)535-0373 U1 = (UNIT( I SEAT) (DOB' (SEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME'/SADDRESSi 7(TELEPHONEI (EMSi (HOSPITAL) 1 4 03 /1 2/2018 M 12 4 0 1 0 Nicholas Meilahn/8N689 BURLINGTON RD-HAMPSHIRE.IL.60140 Elgin Fire Refused U2 996 (224)245-6667 m 2 6 09 /1 4/2023 F 13 4 0 1 0 Kaylana Hunter/210 RIVER HAVEN DR-EAST DUNDEE-IL-60118 El in Fire Refused #OCCS > (773)501-2817 _ g73 2 6 01 /22/1992 F 2 4 C 1 0 Alexandra A. Bangiorno/221 RIVER HAVEN DR,EAST DUNDEE,IL,60118 Elgin Fire Refused Ut 2 m (224)535-0373 ' D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 co 9/ /12 /24 12 45 ®pm in a Work Zone? El N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 1 C) T 2 ID 28 03 ! / ❑PM ❑Construction * cs 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Sobieski,Amanda, M. 11-601-Ax W436-652 / / El PM SLMT o U ❑CITATIONS ISSUED 0 PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility N 8 AM 45 ' rr T 2 0 ARREST NAME 1 / ptil ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 436-Lagodzinski. Brian 702 272-Bajak , , ❑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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A unit ADDITIONAL UNITS FORMS . D r_.._r____ ; ; 8 _� } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I ; i ; ; combination) or INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', i 33 -t ` r r r (example.shuttle or charter bus)-or XI ES ; � unR t � 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 ---- ----1 Illi J ., f } } } transporting employees in the course of their employment(example employee XI E transporter-usually a van type vehicle or passenger car).or w - . 0 , I. r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, t/1 for direct compensation(example:large van used for specific purpose).or O 11 L____--___-; _ i } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires Not To Scale ( i placarding(example placards will be displayed on the vehicle) 71 T. CARRIER NAME Z t ADDRESS 0 L. BpaAan?Or (�cn • • CITY/STATE/ZIP r , - MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r----±----: i • ^ USDOT NO. ILCC NO. m xl , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't N White Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE