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HomeMy WebLinkAbout2024-00059342 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi IIIIIII II 11111111111 11011011011011111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035651 4. u, 1 U2 1 1 1 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 12 U1 1 U2 1 *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 ®$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059342 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1'I BIG TIMBER RD ®gin El ❑Y coN 09 16 2024 02:19 ❑AM ❑YES ®NO U1 • ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m Eg32°93/MI N E S® North Randall ) PEDALCYCUST® ® FREE FLOW # LNS O 110 DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O ,Avelina 0 5 / 1 5 J 1 9 6 5 Chevrolet Traverse 2014 Do-NONE 11 12 i' 1 DUE TO CRASH ❑ IN NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10)• .r 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 875 HIAWATHA DR F ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16-TOP 3 .Distraction Value ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 6 II 6 i' 4 COM VEH 0 ® 1 O ~ 1GNKRJKD3EJ198134 State Farm ®Y ❑N U2 43 . m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 Nov ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) V N U1 m m / J1 9 FOR DAMAGED AREA(S) fi20Nf �RASH ® n NAME(LAST,FIRST,M) Woods, Rodney, L. 8 day yr 8 Unknown Unknown 00-NONE73 13-UNDER CARRIAGE 11: 12 1 z FIRE ❑ 98 —Ia El ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 j DISTRACTED 0 ® SPOR n SYSTEM ENGAGED 9 15-OTHER 9 16-TOP 3 X IN 9 0 a` 2411 COVE CT M ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF NTACT 1 7.II-6 .5 CUOM VEH Sidebar 0 U1 C ZAurora I L 60504 0 2931224 I N I 0 fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (708)268-0797 W320-7327-8248 IL A 7 UNKNOWN Liberty Mutual Insurance ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Fedex Freight INC. 016227418 BAG ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 2200 FORWARD DR, Harrison,AK,72601 (386)956-1079 U1 = (UNIT) (SEAT) (DOB) (SEX) ;SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME II)ADDRESS)U(TELEPHONE) (EMS) (HOSPITAL) n / I uz 996 r m / - #OCCS D / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 co 09/17 /2024 02 19 0 pm in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 a 2 0 2 20 ! / 0 PM ❑Construction * 1 N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Villalobos.Avelina 3-707 494000321 / / ❑PM SLMT o U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility p N AM 45 1 D T 2 0 ARREST NAME Villalobos,Avelina 11-905 494000320 r / 8 pti1 El Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 494-Kirsh, Katherine 701 - 10 ,08/2024 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . r 4 r 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 • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i 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 } - t transporting employees in the course of their employment(example.employee 7, 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 placarding(example placards will be displayed on the vehicle) 11 CARRIER NAME FedEX Z .. ADDRESS 2200 FORWARD DR To • CITY/STATE/ZIP Harrison 1 AK/72601 o , , . ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r-----.-----, , r r r r , DO- 239039 ILCC NO. m US T NO XI , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No XI 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? 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 2 Z Form Number 0 m XI 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. Z White 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. 0 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE