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HomeMy WebLinkAbout2024-00061862 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III III 0 lu II 1111111111111111111 � III IIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035r2230* u, 1 U21 1 1 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 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 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061862 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT N MCLEAN BLVD ❑Elgin RELATED ❑Y co" 09 27 2024 09:55 ®AM ❑YES ®NO U1 ,•< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W TODD FARM ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O Kia Motors Co rte 2017 00-NONE D,IETOCRASH r J NAME(LAST,FIRST,M) ,CATHY, L. mo day yr �° 11 12 �' El DI E 13-UNDERCARRIAGE 10) 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 5 m 2225 POINT B LV D 212 F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH 0 El 1 0 a ~ 3KPFK4A71 HE149950 STATE FARM ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 2592378SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X ❑Y ❑" 2 G) s ®DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDALL ❑EQUES ❑NUV ❑NCV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Gonzalez Martinez, Estefania 0 5o day yr 0 8 1 9 9 9 Jeep(after 1960rokee 2019 00-NONE +c 1 12 s FIREETocRasH ❑❑ ® U2 2 C-2 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a` 421 MAY ST F SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN 'Detraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 9 _II a I. CIOMe6 Bee SidebaH r ® UI H ELGIN IL 60120 B AR55886 IL 2025 I • 0 fC/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)715-5839 0 1 C4PJ MCB1 KD419308 ALLSTATE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 912373655 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑ Same U1 = (UNIT( I SEAT) IDOBi (SEX) (SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME i/SADDRESSII(TELEPHONEI (EMS( (HOSPITAL) 996 1 4 07 /27/1990 M 9 4 0 1 0 KEVIN D. REESE/207 RIDGE CIRCLE,STREAMWOOD,IL.60107 U2 m m 1 3 02 /25/1963 F 9 4 0 1 0 Connie S. Jones/207 RIDGE CIR,Streamwood.IL.60107 - #OCCS D (6301736-9664 X / / U1 3 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 11 1 91 /71 /024 09 55 ❑pM in a Work Zone? ®N DIRP CO 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMU1 6 a 2 0 2 99 ! J 0 PM ❑Construction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. I EMS ARRIVED TIME 5 z ❑AM ❑Maintenance U2 CO 11 1 ARREST NAME REESE,CATHY. L. 11-906 W214-1777 / / ❑PM SLMT o U ❑CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N B AM 30 2 0 ARREST NAME r / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. I COURT DATE TIME AM Workers present? El Y 30 244-Blomberg, Michael 502 272-Bajak r / ❑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 ; _r } A CMV is defined as any motor vehicle used to transportproperty and.passengers or D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I ; 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 } ', ', i N I. r r r (example'.shuttle or charter bus)-or n i____A____, 4 , Not To Scale �� } t porongemployeeslinthecourseaoftheiremployment(example�emaployeerier OM 3. Is or fewer } trans transporter-usually a van type vehicle or passenger car).or 03 i____A____: : i , 1 i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or i_ ".____; ; . , c - i } i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 placarding(example placards will be displayed on the vehicle) 71 T. CARRIER NAME Z ' t ADDRESS 0 N . • CITY/STATE/ZIP O MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m 7.1 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Blue 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