Loading...
HomeMy WebLinkAbout2024-00063442 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 111111111111110111111111110111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003577290* u1 9 uz 1 3 4 1 U199 uz 1 U199 U2 1 U199 U2 1 1 10 Ut 1 u2 3 *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 (83ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00063442 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 LILLIAN ST ® ❑ Elgin RELATED ®Y ❑N 10 04 2024 05'08 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W S MCLEAN ) Kane HIT&RUN ®Y El 11' PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑ECUES 0 NIN 0 r)cv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 ,0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH 021 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 Ill SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 El U2 3 m r PLATE NO. STATE YEAR { 6 i COM ER 1 w F ID VIN INSURANCE CO. EXPIRED 1 UNK El ❑N U2 I— m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Ya Same UNK 1 r o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU L ❑Y ®N 99 0 5 ®COWER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut Y N m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) WaICZyk, KaSSandfa, M. mo �ay 1 yr 9 9 8 Chevrolet Cruze 2016 00-NONE 11: 12 1 REOCRASH 0 ® U2 273 v 13-UNDER CARRIAGE o .?_Z C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® SPDR C SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 0 X a 4675 HERON D R F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN ••Distraction Value to N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RIST CNT OONTACT g O II a I_5 FCIOM6VEH Sidebar ® U1 H LAKE IN THE HILLS IL 60156 0 EJ77975 IL 2016 REAR •f 0 fC/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 421-8023 W422-5139-8634 IL D 0 1 G 1 PE5SB1 G71 10898 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 972047420 BAC• 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y NR Same U1 = (UNIT) (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - #OCCS y / / U1 1 m I 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 1 1 10,04 /2024 05 08 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME DAM It YES check one below: U1 7 C) T 2 ❑ 20 28 ! / 0 PM ❑Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q 1 CO 11 1 ARREST NAME / / 0 PM SLMT o U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility NAM 30 2 ❑ ARREST NAME 10/04 /2024 05 08 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1526-Walsh.Jacob 602 / 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. 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 transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I- I I i combination) or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. d i ® -` ` 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 t•----.....___i, i ._ _ I -i i- - i transporting employees in the course of their employment(example.employee ,3 I transporter-usually a van type vehicle or passenger car).or w I r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I for direct compensation(example:large van used for specific purpose).or O L_____L___-; ; . , -' I "' t i. i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 11 —— placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME 2 ' 11401) I r ADDRESS D I to • CITY/STATE/ZIP r , 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 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 Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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