HomeMy WebLinkAbout2024-00060267 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III HI IIII lull
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III II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035 937'
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
14
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00060267 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'r'I
SHANNON PKWY El In ID
®Y ❑N 09 20 2024 06'49 ®AM El ®No ut ,<
g PRIVATE mo /day I yr ❑PM FLOW CONDITION m
1 COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
® �/MI NOS W Rt 20 Hwy WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 6 / 2 1 /2 0 0 6 FOR DAMAGEDAREA(S) FRONT TOWED
FIREE Ut
NAME(LAST,FIRST,M) mo day yr
, Imani,J. Chrysler Sebring 2006 00-NONE 13-UNDER CARRIAGE 11 ( 12 I ,2 DU ❑
; TO CRASH ®❑ ®
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® 0 <U2 m
SYSTEM IN ENGAGED Q OTHER 9 16-TOP 3
1255 FLEETWOOD DR 309 M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value ALGN ..
r CITY PLATE NO. STATE YEAR POINT OF 8 I{ 6 II.4 COM VEH 0 El 1 0
a ~
1C3EL66R56N113920 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn
a
Thomas,Tyrone. M. 3396000SP13 2
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
o RESPONDER 3 1255 FLEETWOOD DR 309, ELGIN , IL, 60123 (224)258-4521 VEHU G1
®DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDALL ❑EQUES ❑NUV ❑NCV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
5 NAME(LAST,FIRST,M) Schmidt, Karina, B. Omo 5 05y 1 9 7fr 2 Honda Odyssey 2008 00-NONE O' 12 y DUE TO CRASH 0 2Xi
13-UNDER CARRIAGE 101 ! 2 FIRE ❑ 21 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR C)
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 O
a 3314 HIGHWOOD CT F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value
to
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RIST COONTACT F 11 7_11 8 LaCIfOMeeVSee sidebar
® U1
ELGIN IL 60124 C TARAHIS IL 2025 FIEAR 0 CC/1
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(773)339-8937 S530-5027-2729 IL D 5FNRL38638B003593 Auto-Owners ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 5515172900 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
0 Y N 3 Same u1 =
(UNIT) (SEAT) ;DOB) ISEXI (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMSi (HOSPITAL)
I I - U2 996 1-
m
- #OCCS y
/ /• 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 4 09/20 /2024 06 49 ❑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: ut 7 C)
T 2 0 28 10
! / 0 PM ❑Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
0 AM 0 Maintenance U2
Q •CO 11 4 ARREST NAME McPherson, Imani,J. 11-601 298001112W / / El PM SLMT
o U ❑CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N II AM 45
2 ❑ ARREST NAME I / ptit ❑Unknown work zone type Ut
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR 10. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
298-Lopez, Mirko 800 275-Engelke I / p 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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
r r_.._r____1 1 , ACMVisdefinedas any motor vehicle used to transport passengers or property and.
0D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
✓ 'I 1 i ; i ; ; combination) or 'I
INDICATE NORTH 7:1
. y BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ', ', i CM -t ` r r r (example.shuttle or charter bus)-or
0
' ' Not To Scale J t } (- i transporting employeeslin the course theirem and operated
(example�emaployeerier ZI
J IL Ax. transporter-usually a van type vehicle or passenger car).or 0
I : :
r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C
8h�^n°^?Pln"tr. for direct compensation(example:large van used for specific purpose).or
1 f cl1r, iz i n. i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires in
placarding(example placards will be displayed on the vehicle) 71
m
ill . �I i CARRIER NAME
Z
' ........, i
ADDRESS '�
N
O
CITY/STATE/ZIP
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MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r ,
USDOT NO. ILCC NO.
, Source of above z
. MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
z
Form Number 0
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
' TRAILER VIN 1 m
N
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 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y
Gold Blue.Light
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons/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/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE