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HomeMy WebLinkAbout2024-00061457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III III ll II 11111111111 110111011111101111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356E428 u, 1 U2 1 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 Uz 1 1 15 Ut 1 uz 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061457 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 W HIGHLAND AVE ❑Elgin RELATED ®Y ❑N 09 25 2024 04:04 ❑AM ❑YES ®No u1 ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W N AI R LITE ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nav ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 4 / 0 6 /1 9 3 5 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) g mo day yr R&N , II a.A. Jeep(after 19erokee 2017 00-NONE 11 1 DUE TO CRASH El 13-UNDERCARRIAGE FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ISl U2 O m 38W361 B I N N I E RD F SYTM❑Y ®SNE❑UNK VEH. O AT CRASH D 0 99-U 15-UNKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF s it li 4 COM VEH 0 El 1 n jL FIRST CONTACT 1 7 :I a -5 'If Yes,See Sidebar U1 0 Z 1C4PJMCS4HW557101 County Financial ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same Al2A1435246 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 17 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 0 / / FOR DAMAGED AREA(S) FRONT TOWED WDCRASH NAME(LAST,FIRST,M) Everett. Krista,A. mo day yr 1 9 9 5 Dodge Durango 2013 00-NONE It r 12 , ❑ ® 2 v 13-UNDER CARRIAGE 10 j i p FIRE El 2] U2 C , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR C) E 379 N MELROSE AVE F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y E l N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T IOONTACT 1 TF _II a I_5 C•IOMe6 3eeSidebaH ❑ ® U1 al ~ ELGIN IL 60123 0 Y938037 IL 2025 If 0 CCI) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)209-8930 E163-5019-5716 IL D 0 1C4RDJDGXDC693978 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Kenar-Steven.J. 3018358SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 379 N MELROSE AVE. ELGIN - IL.60123 (847)209-8923 U1 = (UNIT( (SEAT) {DOB) (SEX, 'SAFT) (AIR) IINJI (EJCT) (EPTHI PASSENGERS&WITNESS ONLY (NAME)/;ADDRESS)/;TELEPHONE) (EMS) (HOSPITAL) 2 6 08 /1 7/2023 M 13 3 0 1 Logan Mason/379 N MELROSE AVE.ELGIN,IL,60123 U2 m 996 m - 2 4 09 /3 0/2016 M 11 3 0 1 Vincent E. Staine/379 N MELROSE AVE.ELGIN.IL-60123 #OCCS D (847)209-8930 _ X / / Ut 1 m / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 09/25 /2024 04 04 ®PM in a Work Zone? El N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 1 a 2 ❑ 2 18 ! / PM El Construction * r� T�A 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 ® 11 4 ARREST NAME Dudziak. Ilga,A. 11-901-A 492000432 / / El PM SLMT o u CI CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N 8AM 30 2 ❑ ARREST NAME / / ptil ❑Unknown work zone type Ut 2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 492-Gardrer. Mikaela 602 334-Fries 10 / 15/2024 09 00 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. 0_ IF 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer combination)or 'I r ; , 1nvKas7ar ! INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ', 1 I -! ` r r r (example'.shuttle or charter bus)-or 0 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----;-----4 4 i -t t r - r transporting employees in the course of their employment(example.employee M tr -usually a van vehicle or ca i.____A____: : , iiiI wmoitkinirrave. i r i 4a Is usedror designated to trransport between 9 and 15rpassengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____-:_____; ; ; , — uKiwe - t y 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 1111611. .-P.a.i. placarding(example placards will be displayed on the vehicle) 711 /T CARRIER NAME ' I ADDRESS 0 N ' A I CITY/STATE/ZIP Not To Scala i • - MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. , Source of above Z 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? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? O ❑ 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 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 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Silver Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE