Loading...
HomeMy WebLinkAbout2024-00058357 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II 010 �1 1IIIIII 11111111 11111 IlfillIllU 110 1111 Ill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY n035609 3 u, 1 U2 1 3 4 1 U1 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 202412024-00058357 VENT ' ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 S RANDALL RD ® ❑ Elgin RELATED ❑Y coN 09 12 2024 11:35 ®AM ❑YES ®No u1 • ,-‹ PRIVATE mo /day/yr ❑PM FLOW CONDITION m 1 COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U1 ® �/MI N E O W South St WITH VEHICLES INVLD ® STOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS ' O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Rcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED Ut 0 NAME(LAST,FIRST,M) , Kathryn.A. mo 1 1 / day yr 8 J 1 9 5 6 Nissan Versa 2013 00-NONE 11 O� , DUE TO CRASH ❑ 21 13-UNDERCARRIAGE 191 I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 416 PARK ST F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 (� e l 4 COM VEH ❑ ® 1 O a ~ 3N1CN7AP2DL849688 Progressive ❑Y ®N U2 18 . m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 941997791 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 73 L ❑Y ®N 2 17 O ®DRIVER ❑ PARKED 0 ORNERLESS 0 PED ❑PEDAL ❑EQUES 0 RUM ❑rav 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED , NAME(LAST,FIRST,M) ShOCICey, Lisa, M. 0mo day 1 9$9 Mitsubishi Mirage 2022 oo-NONE +c I 12 I. s FIREETocRasH ❑❑ ® Uz 2 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPDR 0 E. 520 S BLACKHAWK CI F SYSTEM IN 0 on ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •DistracoValue 01 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 6 7_1I rill OS C•IO gee SidebarH ® U1 C ZC SOUTH ELGIN IL 60177 C DH36620 IL 2025 ��aR 0 fn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)639-3385 S200-5338-9691 IL D 0 ML32FUFJXNHF03404 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 1521785SFP13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N 181 Same Ut _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) I I U2 996 1- m / - #OCCS D / /• U1 1 m I I 1 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 91 /21 /024 11 42 ❑pM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ®AM U1 1 2 ❑ 03 99 91 /2/ /024 11 42 ❑PM ElConstruction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ®AM ❑Maintenance U2 ® 11 1 ARREST NAME Doherty. Kathryn,A. 11-601 W1512400 9/ /2/ /024 11 48 ❑PM SLMT o U CITATIONS ISSUED PENDING • ROAD CLEARANCE TIME 0 Utility o N ❑ ❑ SECTION CITATION NO. AM 45 T 2 0 ARREST NAME 9/ /2/ /024 11 57 ®PM ❑Unknown work zone type U1 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 1512-Juarez-Huichapan,Juan 800 404-Duffy / / 0 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. _ F MOREany TmoHANtorvehicle ONE CMV IS INVOLVED,transport USE SRpassengers 105or0pAroperty ADDITIONAL UNITS FORMS , I I _� r A CMV is defined as used to r,01 Has a weight rating more than 10,000 pounds(example Z truck or truck/trailer Z r r I I , I I combination) or and. • INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I i I I I t ` r r r (example shuttle or charter bus) or n / a.o a 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� 4 -! } } } transporting employees in the course of their employment(example.employee 0 transporter-usually a van type vehicle or passenger car).or CO i_____A____: : , " - - I E r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) fo ect ensation( xample. van used i } 1 5 r Is'rany vehicle usedtotransportla nehazardous for materialspecific (HAZMAT)purpose) that requires 11 O / placarding(example placards will be displayed on the vehicle) 71 T. ,d,� Q CARRIER NAME Z Rd I N ,. ADDRESS LI D ' • I I� • CITY/STATE/ZIP • MOTOR CARR ID ❑ Interstate ❑ Intrastate Not To Scale j ❑ Not m Comm./Govt. ElNot rn Comm./Other 00 " "' i i I I I USDOT NO. ILCC NO. m 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? O ❑ 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m CA LOCAL USE ONLY TRAILER VIN 2 m 0 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. y Red Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE