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HomeMy WebLinkAbout2024-00059636 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111 lIHIUflI 11111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003565131. u, 1 U21 3 4 1 U1 5 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 3 *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 1 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00059636 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 '17 S MCLEAN BLVD ® 0 Elgin RELATED ®Y ❑N 09 17 2024 04:33 ❑AM ❑YES ®No u1 ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m 050 ®/MI N E S® Rt 20 COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ElSLOW VEHICLES INVLD 0 STOPPED U2 1 N —I❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN 0 Y CZN WITH PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 Nav ❑ace 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n Frei CdO FOR DAMAGEDAREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) , D. mo 02 / day J yr 1981 g p'k 2021 00-NONE ®1® j.12 J _1 13-UNDERCARRIAGE 2 D,I FIREETOCRASH 0 21 0 ® 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 53 U2 m 10628 S UNION AVE M ❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16-TOP 3 .Distraction Value ALGN I CITY PLATE NO. STATE YEAR FIRSNT T COONTACT 1 O 6 -:_S COM f y„$See SldeDa®EH El El U1 1 Q c Z 3AKJHLDV7MSLG9679 ACE American Insurance Co ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m J-B_ Hunt Transport XSAH1076516A 1 m Ei HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o 0 y°®EN 9200 E 146TH ST. NOBLESVILLE. IN .46060 (479)820-3234 vEHu 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 98 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) Rico Segovia.Jaqueline.C. 1 20 1d y 2 0 y0r 0 General MotorSitimp 2015 00-NONE 10 12 s FIREETocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �,,�DISTRACTED 0 ® SPOR n SYSTEM VIN 9 ENGAGED 9 15-OTHER 9 16-TOP® 0 a 805 BAUTUSROL DR F ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 II �I O COM VEH 0 ® Ut to F, FIRST CONTACT 4 7_- a ._S •Itvee.See Sidebar Elgin IL 60123 0 3513157B IL 2024 is 0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)606-6387 R222-4230-0958 _ _IL D 0 3GTU2VEJ7FG496283 First Chicago Insuance Co ❑Y El RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same I LS 809026-03 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Same U1 = (UNIT) i SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) -Bryant J. Hayes/ 996 '- 1 3 07 /1 8/1980 M 2 3 0 1 0 (312)622 4759 _ Refused U2 m I I #OCCS y /• / u i 2 m / 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 09/17 /2024 04 33 ®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 4 C) T 2 ❑ 20 06 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 6 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Hines.Shedrick. D. 11-708 494000325 / / El PM SLMT o U CI CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N BAM 30 2 0 ARREST NAME , / ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 494-Kirsh. Katherine 701 334-Fries 10 ,08/2024 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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS • . . . • 0} 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 truck/trailer Z i- 1 ; i ; i- r r , , i INDICATE NORTH combination).or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----i-----• I I • : ' - 1 1 1 i 't } - 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 designated to transport between 9 and 15 passengers,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) 71 M CARRIER NAME J.B. Hunt Transport Inc. z .. ADDRESS 615 J.B. HUNT CORPORATE DR O o CITY/STATE/ZIP Lowell 1 AK/72704 . ^ MOTOR CARR ID ❑ Interstate E Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r-----1-----, , r r r r r -, DO . m • US T NO 0080806 ILCC NO , Source of above Z rJ . 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ®No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y White Black - 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