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HomeMy WebLinkAbout2024-00059096 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III HI IIIIIII II 11111111111111H11 101I 1 U21 2 4 1 U199 III lUllIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553956 u, u2 1 U, 1 u2 1 U1 1 U2 1 1 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00059096 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'tI N MCLEAN BLVD ®gin El ®Y ❑N 09 15 2024 09:18 ®AM El ®No u1 ,< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W EAGLE R D 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El SLOW 1 Cl, ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 1 2 FOR DAMAGED AREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) ,Jeanette, E. Chevrolet Cruze 2013 00-NONE mo / day 31 J yr 0Q D DUE TO CRASH ❑ 21 13-UNDERCARRIAGE 10i z FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 12853 COLD SPRINGS DR F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF . • COM VEH ❑ ® 1 O0 FIRST CONTACT 11 7_ .i 6-::.5 ^Yves,See Sidebar U1 Z 1 G 1 PE5SBXD7304356 Country Financial ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same P12A3344080 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 G) 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 Nov ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m 12 / 31 J FOR DAMAGED AREA(S) FRONT TOWED CRASH Y N n NAME(LAST,FIRST,M) Daman,Jospeh, M. mo day 1 9 4 1 Dodge Challenger 2021 00-NONE 1tr 12 1 ❑ ® 2 Xi a 13-UNDER CARRIAGE 10 i ! 2 FIRETo El MI U2 C , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 E. 1020 CATAMARAN CIR M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN %-Distraction Value 0 to H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 7 O7 © OS Clfve6M V See Sidebar 0 ® U1 C EH PINGREE GROVE IL 60140 0 FLPNFST IL 2024 R 0 C TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)456-0318 0635-4937-5197 IL D 2C3CDZFJ3MH622829 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 2140630-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < ElESPOQ RESPONDER Same U1 = (UNIT( (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 06 /20/2010 M 2 4 C 1 Ethan Gartzke/1981 AARON CTIL,60140 Elgin Fire Refused U2 996 (630)333 2760 _ m 2 4 05 /2 0/2011 M 2 4 C 1 Joseph Ortman/1020 CATAMARAN CIR,PINGREE GROVE,IL,60140 Elgin Fire Refused #occs y 2 3 04 /03/2013 F 2 4 C 1 Madelyn Ortman/1020 CATAMARAN CIR,PINGREE GROVE,IL,60140 Elgin Fire Refused Ut 1 m D / / 4 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 4 09/15 /2024 09 18 ❑pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AMU1 4 a 2 ❑ 2 99 / / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ARREST NAME Redeker,Jeanette, E. 11-901-A 414- / / ❑PM SLMT 1 CO11 4 0 Utility p U CI CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 414-Lara, Raul 601 - 09 , 15/2024 09 00 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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or —I INDICATE NORTH XI A I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` I ', i N -` ` r r r (example'.shuttle or charter bus)-or n X `-- ` 1 ' ' ' Not To Scale I I i } - i transporting employeeed to slin the cours5 or fewer e their employrs and ment(example�emaployeect rier ZI transporter 1 [ -usually a van type vehicle or passenger car).or w i_____-:---__: : i I I i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) for direct compensation(example:large van used for specific purpose).or O Vii11 L____- -1 , - i i 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires — _ placarding(example placards will be anyisplayed on the vehicle) 11 CARRIER NAME Z — I I ADDRESS 0• . 1 r cn . I I : • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . ❑ Yes ❑ No ❑ Unknown M 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 Tan Red u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑,r 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