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HomeMy WebLinkAbout2024-00063482 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 MMM11.1111110H DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo6357ea95 u, 1 u2 1 1 1 U199 U2 1 u, 1 u2 U, 1 u2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00063482 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 10 04 2024 12,—AM ❑YES ®NO U1 -< LONGCOM MON PKWY Elgin mo /day/yr 10:36 ®PM FLOW CONDITION m _ _ 25 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n ® FT/0 ON E S W South St WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ID PARKED El DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 0 8 / yr q 1 i,• 12 .O E FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 1 r<r1 M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a ii.4 COM VEH 0 El 1 0 ~ ELGIN IL 60124 0 1 0 FIRST CONTACT 1 7 . -_5 *IrYes.See Sidebar U1 Z EU51641 IL 2025 E TELEPHONE IL D 3GNAXLEX2LS654302 National General ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Williamson.Jennifer. L. 2024665183 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 0 DRIVER I} PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 Nuy 0 CIRCLE NUMBER(S) U1 NCv 0 Dv yr 13-UNDER CARRIAGE 10 ©I,, E FIRE ❑ El C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C) a SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O 14 COM VEH D ® ut toF.... O7 v =w__:.=5 •IfYes,SeeSidebar DZ50374 IL 2025 REAR 9 N M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0 1 FADP3F29HL339296 USAA ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Reed. Nathan. E. 0130303577104 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 18 1 10/04 /2024 10 36 ®AM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 28 41 ) / ❑PM ❑Construction * 1 R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 oD ® 11 1 ARREST NAME Williamson. Brady.J. 11-601-Ax 1517000341 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility El t 2 El ARREST NAME AM 7 / / pM El Unknown work zone type 30 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1517-Le Cates. Brittany 801 11 / 19/2024 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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; 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 truck trailer -< i- }--_.r-_--; } combination):or —I s INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ii j - (example:shuttle or charter bus):or 0 }----A----i -; 3. Is designed to carry15 or fewer passengers and operated a contract carrier O ` } } } transporting employee In the course of their employment(example:employee L-1 transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or o L L____a____. / - t i. ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D �++� placarding(example:placards will be displayed on the vehicle). ,Zmt —1 , c CARRIER NAME Z ADDRESS 0 D r r T 1 \ i. i. i. i. 4. cCITY/STATE/ZIP0 g MOTOR CARR.ID 0 Interstate 0 Intrastate _tarmswr.: o I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 •- USDOT NO. ILCC NO. m XI Source of above z ' . 0 Yes 0 No ❑ Unknown A Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE