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HomeMy WebLinkAbout2024-00059646 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III IIII IIIIIII II II 11111111IllIllHl 101 11111 III 110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355553$ u, 1 U2 1 3 4 1 U116 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059646 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '�'1 KIMBALL ST ® ❑ Elgin RELATED ❑Y coN 09 17 2024 05:37 DAM ❑YES ®NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m EP (0/MI N 0 S w North State ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O ,Susan, L. 0 9 / 1 8 J 1 9 6 4 Ford Explorer 2015 00-NONE 11 DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 12 13-UNDERCARRIAGE 21 19I <i 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 1450 PLYMOUTH LN F ❑Y IN NSYSTEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0 1 FM5K7F86FGB08527 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 2426566SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / J FOR DAMAGED AREA(S) Fi20 IT TOWED NAME(LAST,FIRST,M) Sarovic. Mirko mo �a 2 yr 0 2 Genesis G70 2023 00-NONE 1G 1 12I. s FIREo CRASH O ® U2 2 C I', 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR n a` 612 SHENANDOAH TRL M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® El UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR POINT OF ,II II COM VEH 0 U1 to 1— .i'FIRST CONTACT 7 t -� 6 - ®5 •If Yes,See Sidebar C ELGIN IL 60123 0 EG43015 IL 2024 FIEAR 0 P/) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)245-0859 S612-5400-2158 IL D 0 KMTG54TE7PU111308 Geico ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 6168647516 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y NR 181 N Same Ut = (UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m /• '#OCCS > / /• U1 1 m Ito I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ElY U2 Z N ® 11 1 91 /71 /024 05 37 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) T 2 0 20 18 ! I 0 PM ElConstruction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q •® 11 1 ARREST NAME Chereck.Susan. L. 3-414 492000428 / / ❑PM SLMT o U ®CITATIONS ISSUED •❑PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility N AM 30 2 0 ARREST NAME Chereck.Susan. L. 11-708 492000429 r / 8 ptil ❑Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 492-Gardrer. Mikaela 102 - 10 115/2024 09 00 ❑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 D _� } 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 i 1 i combination).or —I INDICATE NORTH 7:1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '- ', +, +, N,net iw 1. -I' ` r r r (example'.shuttle or charter bus)-or n X 0 ; I ro.l. designed 1 or fewerpassengers and operated by a carrier ----?----- + -i } } t transporting employeesin the courseof their employment(example�emaployeeM Ip„a,,y� transporter-usually a van type vehicle or passenger car) or � �____A____: : i ; I : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) utriwn for direct compensation(example:large van used for specific purpose).or 0 — — — — L____L____; I H — — - i . i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires II - — — — 4.�.�'�aY rtl placarding(example placards will be displayed on the vehicle) � r uMlt ono D CARRIER NAME I , ADDRESS 17 . Not To Scale I N CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above 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 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 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver White - 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