Loading...
HomeMy WebLinkAbout2024-00062540 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 1111111111111111111111111111 � III DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035 2235 u1 2 U2 1 1 1 U1 9 U2 1 U1 1 U2 U1 1 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00062540 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT DOUGLAS AVE ® ❑ Elgin RELATED ❑Y coN 09 30 2024 01'54 ❑AM ❑YES ®No ut ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m ^ 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR El SLOW 15 N 12S,� ®/MI N E CI W Division St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES 0 SIN 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 2 / 2 8 J 1 9 6 9 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 . Michael.A. Toyota Corolla 2005 00-NONE 11 12 I 1 DUE TO CRASH ❑ 21 - NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10)• I, 2 FIRE 0 1l < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 1 HOMELESS ST M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN CITY PLATE NO. STATE YEAR POINT OF 1 6 ii_ COM VEH 0 ® 1 0 ~ 1NXBR30E05Z549267 Direct Auto ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same PAIL001149421 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER LR❑ESPON❑DEnR 3 Same VEHU 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES 0 NMV ❑NKV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Buick Envista 2024 00-NONE 1t' t2 0 DUE TO CRASH ❑ 21 1XI c 13-UNDER CARRIAGE 10 j j 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 IN SPDR 0 ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 11 6I._ COM VEH ❑ ® C F FIRST CONTACT 1 7_-._5 •(rYes,See Sidebar EJ76076 IL 2025 REAR 0 I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KL47LBE22RB099525 State Farm 0 y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Bondi. Phillip- M. 1761588-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 997 < RESPONDER 1832 LANCSH U RE CT.Schaumburg• IL.60194 (630)258-4384 U1 = (UNIT) I SEAT) (DOB) (SEX) (SAFT) (AIR) )INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)(tTELEPHONEI (EMS) (HOSPITAL) Steven P Kroiss/1528 MAPLE LN .ELGIN.IL,60123/ 996 r W 07 /31 /1984 M (63on7o 9757 U2 m / / #OcCS > / / u1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 18 1 09/30 /2024 01 54 0 pp,1 in a Work Zone? El 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 5 0 T 2 ❑ 08 99 ! / 0 PM ElConstruction * N 1 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Osullivan. Michael.A. 11-1402-A 752341 / / ❑PM o U ®CITATIONS ISSUED ❑PENDING TIME 0 Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM 30 2 0 ARREST NAME Osullivan- Michael.A. 11-501-A-2 752340 r / 8 pti1 Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? El 30 414-Lara. Raul 101 272-Bajak 10 r 21 /2024 09 00 ❑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. r 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< i ; i r r , , i r r INDICATE NORTH combination) or 'I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ' t ` ` 1 ` ` 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------i-----• + + • : - 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M 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 m placarding(example placards will be displayed on the vehicle) Z1 CARRIER NAME Z ' .. ADDRESS 0 N O CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r---- ----, r r r r r----, r DO ILCC NO. m U N XI Source of above Z . 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 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 Blue Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO ,Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE