Loading...
HomeMy WebLinkAbout2024-00063187 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIII lull 1111111111111101111HI 1111 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;4355 u, 1 U2 1 1 1 1 U1 5 U2 1 U, 1 U2 1 Ut 1 U2 1 1 9 Ut 1 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 • 7 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-00063187 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'I'I S RANDALL RD ® ❑ Elgin RELATED ❑Y co" 10 03 2024 03'46 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m Ell 09,/MI N E S® Weld Rd 'COUNTY PROPERTY ®Y ❑" DOORING ❑y #OF MOTOR ❑SLOW 15 N Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 ORNERLESS ❑ PEE ❑PEDAL 0 EOUES 0 NIA/ ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O 0 0 2 / 2 8 J 1 9 6 3 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) -Stowers, Editha.Z. mo day yr Volkswagen Atlas 2021 00-NONE 11 121 y,DUE TO CRASH ❑ DI E 13-UNDERCARRIAGE �/ FIRE ❑ ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 1l U2 O m 2464 VISTA TRL F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UNKNOWN THER 9 76-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0 1 V2TR2CA1 MC510167 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Poliarco.Ariesienne,C. 2256907SFP13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 769 N SHADY OAKS DR, ELGIN , IL,60120 (214)405-5342 VEHU G1 0 DRIVER ® PARKED 0 DRNERLESS ❑ PEE ❑PEON. ❑EOUES 0 NlAV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Jeep(after 198�)nmander 2006 00-NONE 11 12 ,_t DUE To CRASH ❑ ® 1 Z1 c 13-UNDER CARRIAGE 10 i I 2 FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPOR X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN ©, 4 •'Distraction Value 9 U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF II FIRST CONTACT 7 ®.. a �_ COM•5 I VSee Sidebar C ❑ ® C Q551538 IL 2024 ljREAR O (n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1J8HG58286C364815 USAA ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Barnett.Shelley- R. 007925697C71010 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N 851 BODE RD, ELGIN . IL,60120 (847)385-8307 U1 = (UNIT' (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 r m / / - #OCCS D / /• U1 1 73 Ito / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 18 5 10,03 /2024 03 47 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 0 28 28 ! I 0 PM ElConstruction * N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 AM ❑Maintenance uz Q CO 11 5 ARREST NAME / / ❑PM SLMT o UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' ❑Utility o N 0 ❑ SECTION CITATION NO. AM 1 O 2 ❑ ARREST NAME 10/03 /2024 03 47 ®PM 0 Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 366-Greer,Adam BOO 334-Fries I / 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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS 4 } 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 i combination) or —I INDICATE NORTH 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 n S ; 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 ,3 transporter-usually a van type vehicle or passenger car).or 03 ' 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 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate Elintrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r - DO ILCC NO. m U N XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No P3 73 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 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 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 Silver Blue - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE