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HomeMy WebLinkAbout2024-00058870 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111 llHl I IllIlIllhllIl IIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356100r u, 1 U2 1 1 1 1 U1 9 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 15 U123 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00058870 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT DUNDEE AVE ® ❑ Elgin RELATED ❑Y co" 09 14 2024 09:40 ®AM ❑YES ®No ut ,-< PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® " PEDALCYCUST®N 0 FREE FLOW # LNS 0 D4 DRNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 1 / 2 9 /2 0 0 2 FOR DAMAGEDAREA(S) FRONT TOWED Ut mo day yr 13-UNDER CARRIAGE 10) 2 ®FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 U2 O m 19 SPARROW RD M SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 = / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN e 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF {I®ji_ COM VEH ❑ ® 1 c Z 1 FTKR1ADXBPA68161 National Union ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Oreilly Auto 6890203 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER > L RESPONDER y°DEN 255 E ROOSEVELT RD,West Chicago, IL,60185 (847)760-6678 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 14 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) Grzeszczak, Barbara,A. 0 mo8 day 1 9 yf 1 Subaru Forrester 2020 DO-NONE '0 12 Y REocRasH 0❑ ® U2 2 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n E 6111 HALLO RAN LN F SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 9 T_II a I_s C•IOMe6 3eeSidebaH ❑ ® U1 to C HOFFMAN ESTATES IL 60192 0 3483199 IL 2025 REAR O Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (312)320-0886 G622-0617-1820 IL D 0 JF2SKAUCOLH588793 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 2857658SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same Ut = /UNIT1 (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJ1 (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)r(ADDRESS))ITELEPHONE) (EMS) (HOSPITAL) / I U2 996 1- m / - '#OCCS > / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 11 5 09/14 /2024 10 30 ❑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 3 C) T 2 0 18 18 ! / 0 PM ❑Construction a N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q ® 11 5 ARREST NAME / / ❑PM 0 Utility SLMT O U CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 10 2 0 ARREST NAME / / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 10 547-Homeler,William 275-Engelke r / ❑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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 ADDITIONAL UNITS FORMS . ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- t L ' ' '. ', ' l' ` 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------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 . n • CITY/STATE/ZIP 0 , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . ❑ 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 White SilverEn - 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