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HomeMy WebLinkAbout2024-00059190 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III HI IIIIIII II 11111111111111H11 IIIIIIIIIIIII III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553951 u, 1 U2 1 2 4 1 U, 5 U2 1 U, 1 U2 1 Ut 1 Uz 1 1 10 Ut 4 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ❑ON SCENE[21 NOT ON 1 VEHICLE/PROPERTY 0 OVER$1.500 El AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059190 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 -1'1 NOLAN RD ® ❑ Elgin RELATED ®Y ❑N 09 15 2024 06:00 ❑AM ❑YES ®NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W BOWES RD 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 er,W. 1 2 / 2 5 /1 9 6 1 Acura MDX 2023 00-NONE ®; 12I I; , DUE TO CRASH p NAME(LAST,FIRST,M) g mo day yr 13-UNDER CARRIAGE 10 t 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 2 m 691 W THORNWQOD DR M ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 76-TOP 3 "DislractlonValue ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 II _ Ii 4 COM VEH ❑ ❑ 1 0 r' 5J8YE1H85PL031596 American Family ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 0478354106 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L • ❑Y ❑N 2 GI s ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / 21 J FOR DAMAGED AREA(S) FRONT TOWED Y N aNAME(LAST,FIRST,M) CHICKERNEQ- NANCY, B. Imo day 1 9 4 6 Infiniti QX60 2020 13-UNDE +c) 12 s REEoCRASH ❑❑ IN U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ❑ SPDR n a` 39W40 HOGAN HILL F SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 X ❑Y ElElN UNK 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 6 I_5 C•IOMe6 3eeSidebaH ❑ ® U1 al ~ ELGIN IL 60124 0 NCHICK7 IL 2025 REAR f 0 CC/>, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)965-8778 C265-6224-6931 IL D 5N1 DLOMMXLC514121 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Same 811384585 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y N Same U1 _ (UNIT) {SEAT) {DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) {EMS) (HOSPITAL) I I U2 996 1- m / - '#OCCS D / / U1 1 73 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 1 09/15 /2024 07 20 ®PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 4 T 2 ID 28 06 ! / 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 50 T 2 ❑ ARREST NAME I / ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 0 AM Workers present? ❑Y 50 537-Sanders, Richard 801 246-Kite I / ❑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 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A 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 truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or —I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` 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------.-----• + + • : - -, 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 nated to trans rt between 9 and 15 assen ers including the driver, 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 • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, - DO ILCC NO. m U N XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No PJ 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? ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 Black BlackEn - 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