HomeMy WebLinkAbout2024-00058222 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II II I III
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003553952-
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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 3
0 NOT ON
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ES) B Injury and JorTow Due To Crash YR 2024I2024-00058222 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
ROUTE 20 HWY ® ❑
Elgin RELATED ❑Y CON 09 11 2024 09:49 ❑AM ❑YES ®No ut .•<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
Ell 0�,/MI N E S® South State
) PEDALCYCUST® ❑ FREE FLOW # LNS ' 0
tg oRNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 7 / 2 9 J 2 0 0 4 FOR DAMAGED AREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) y mo day yr 11z
, Ryan, H. Dodge Challenger 2023 00-NONE 11 l , DUE TOCRASH ® o
13-UNDERCARRIAGE • I, 2 FIRE ®
10 0 4 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL (�-TOTAL(ALL) DISTRACTED ® 0 U2 m
2109 CABRILLO LN M ❑Y ❑SNE❑UNK VEH. 2 IN AT CRASH D 2 99- THER
UUNKNOWN 9 16-TOP 3 "Distraction Value 5 ALGN 2
CITY PLATE NO. STATE YEAR POINT OF 8 )� e l -4 COM VEH ❑ ® 1 0
�, ~
2C3CDZAG7PH524760 Farmer's Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a
Same 198217282 1 I—
t" HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
.5 ❑Y ❑N 2 G�
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m
m 4 / J FOR DAMAGED AREA(S) FRONT TOWED Y N
NAME(LAST,FIRST,M) Noyola. Maria.A. 0 mo laay 1 9 yr Lincoln Lincoln Mark II 2019 00 UNDER CARRIAGE NONE 11 t 12 2 REocRasH O 0 uz 2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 6 ENGAGED 5 15-OTHER 9 16-TOP 3 4
a 332 ARAPAHOE TRL F ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN /� •Distraction Value
F
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST I CONTACTNT O 6 I I mi OS C•(O M gee SidebarH ❑ ® Ut C
Z Carol Stream IL 60188 B DS35076 IL 2024 0 (p
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(630)965-5246 N400-5417-4708 IL D 0 5LMCJ3D99KUL43740 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 4501989406 BAC
' 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
❑ Same Ut _
(UNITE I SEAT) IDOBi (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'/t ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
3 3 01 /04/2006 F 2 8 0 1 0 Lauren K. Hogan/297 LAMONT PKWY.BARTLETT,IL,60103 -
Refused 996 1
(630)137-1597 _ U2 m
W 1 0 /1 7/1990 F Amanda R Palczynski/2484 ALISON AVE .PINGREE GROVE-IL60140/ #OCCS D
(773)505-5046 _ X
/ / Ut 1 m
/ I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ®Y U2 Z
N 1 ® 1 1 1 09/1 1 /2024 09 30 0 pm in a Work Zone? El DIRP
3
1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 C)D
T 2 0 11 1
28 15 ! / 0 PM ®Construction *
c' ' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
AMU2
Q ARREST NAME Scheibe, Ryan, H. 11-601 469002026 / / ❑❑PM ❑Maintenance SLMT
c U , ® 11 1 Igi CITATIONS ISSUED ❑PENDING ROAD CLEARANCE TIME '- 0 Utility
o N SECTION CITATION NO. AM 55
2 0 ARREST NAME Scheibe. Ryan. H. 11-601 169002027 09/11 /2024 11 00 ®PM 0 Unknown work zone type U1
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ®Y 55
469-Taylor,Jonathan 701 - 10 /08/2024 01 30 0 PM 0 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
Route?20 ADDITIONAL UNITS FORMS
. 0
D
r_.._r____ ; ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r ; ', ', N— INDICATE NORTH
combination)or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ', i -! ` r r r (example.shuttle or charter bus)-or X
Not To Scale 1 iip. , :t
3. Is designed to
carry 15 or fewer passengers and operated a contract carrier 0
-----;-----� $ -t t 1. - t transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car) or OJ
i i 4 Is used or designated to transport between 9 and 15 passengers.including the driver, N
! • for direct compensation(example:large van used for specific purpose).or
• •
O
•L____--___-4 i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
12 placarding(example placards will be displayed on the vehicle) 71
CARRIER NAME
' ] ADDRESS 03 N
.•
O
CITY/STATE/ZIP
• ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. Not in Comm./Other
••' --"-�-"'-i i '• • USDOT NO ILCC NO. m
, Source of above Z
. 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 g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID
Yes No ❑ Unknown 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
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Green White
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons I Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO:
DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE