HomeMy WebLinkAbout2024-00062627 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl
III (III (IIIIII II 1111111111111111111111111111111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035/2241
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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 3
El NOT ON S
VEHICLE/PROPERTY ®OVER$1.500 El AMENDEDCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash YR 2024I2024-00062627 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1
S RANDALL RD ❑
Elgin RELATED ®Y ❑N 09 30 2024 08_25 ❑AM ®
❑YES NO u1 • ,•<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
23.25 FT/® N E OS w Bowes
Rd COUNTY PROPERTY ElY ®N DOORING ❑y #OF MOTOR ❑SLOW 1 CD
WITH VEHICLES INVLD El STOPPED U2 CD
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0
18)DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED Ut
O
q mo day yr 13-UNDER CARRIAGE 10 1 .r 2 FIRE 0
IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 M U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
221 MACINTOSH AVE F ❑Y ®N ❑UNK VEH. O AT CRASH 0 99-UNKNOWN 'Distraction Value 9 ALGN 2
r CITY PLATE NO. STATE YEAR POINT OF 8 iI 6 .00OMVEH 0 ® 1 n
~
JNRDR09Y32W262787 General ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Same IL7161989 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 0
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m / J FOR DAMAGED AREA(S) FRONT TOWED Y N
5 NAME(LAST,FIRST,M) Kozlowski, Breanna, M. 1 2 d 0 2 0 0 2 BMW 528 2014 00-NONE it. O!.0 DUE TO CRASH (g 0 2 -I
v 13-UNDER CARRIAGE 10 Ij 2 FIRE ❑ ® U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �O DISTRACTED 0 ® SPDR 17
SYSTEM IN O ENGAGED 0 15-OTHER 916-T� 9 0 X
E. 39W195 CLIFF DR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN II Distraction Value
IV CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COFONTACT 1 7_'1 a 1._4
G•IOMesVEH See Sidebar❑ ® U1
C
H ELGIN IL 60123 B DU90745 IL 2025 lam0 ((n
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)219-0567 K242-0730-2971 IL D 0 WBA5A7C5XED617227 Amica ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 95021222AQ Bnc , 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0 RESPONDER Same Ut 2
(UNIT) I SEAT) IDOBi (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME'/t ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 05 /22/2020 M 12 4 B 1 0 Javi Santiago/221 MACINTOSH AVE.Woodstock.IL.60098 Refused 996 1
(815)505-5211 _ U2 m
1 4 10 /28/2015 M 2 4 B 1 0 Romeo Santiago/221 MACINTOSH AVE-Woodstock-IL-60098 Refused #occs y
(8151505-5211 _ ,�p
2 3 10 /0 7/1998 M 2 8 B 1 0 Javontae D. Harris/3032 CHALKSTONE AVE.ELGIN.IL.60123 Refused UI 3 m
(8 4 7171 5-6 4 0 6 , ' D
W 11 /03/1997 M Jeremy M Finstein/ 1073 CRANE POINT ,Elgin-IL.60124/ 0
(847)756-0502 U2 2 2
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY 1 POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y
N ® 11 1 09,30 ,2024 08 25 ®pM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 7
2 0 25 50 09(30 /2024 08 25 ®PM El Construction *
N 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z ❑AM ❑Maintenance U2
® 11 1 ARREST NAME Santiago, Raquel 11-601-Ax 366-1470 09/30/2024 08 32 ®PM SLMT
o U CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME 0 Utility
o N ❑ ❑ SECTION CITATION NO. AM 50
rY T
2 0 ARREST NAME 09/30 /2024 08 55 El RA0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 50
366-Greer,Adam 800 334-Fries 11 ( 12/2024 01 30 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.
0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
I
ADDITIONAL UNITS FORMS
j
I I I _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
l` 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I 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 ', i 9oww?Rd. -` ` r r r (example'.shuttle or charter bus)-or r7
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_----.....---% 4 - — — — — -i } - i transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or CO
1 r ii 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 O
' ' I S.? ndalLtd_ ( )
___ ; - i. i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires in
placarding(example placards will be displayed on the vehicle) Zml
2.
I Not TO SC8le - CARRIER NAME
Z
II ADDRESS 0N
• CITY/STATE/ZIP 0
J {r ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate
. 0
Pri ate?dive I ❑ Not m Comm./Govt. Not m Comm./Other O
.
44Ii • ^ USDOT NO. ILCC NO. m
XI
, Source of above Z
. 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% A
❑ 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
X1
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Tan Black
-
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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO:
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE