Loading...
HomeMy WebLinkAbout2024-00063566 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III !III IIIIIII II 1111111111111101111111111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;329* u1 9 U2 1 1 1 U1 99 U2 1 U199 U2 ut 99 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 7 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063566 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 KATHLEEN DR ® ❑ Elgin RELATED ❑Y co" 10 05 2024 11:00 ®AM ❑YES ®No U1 .( PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑" DOORING ❑y #OF MOTOR ❑SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ❑ N PEDALCYCUST®N ® FREE FLOW # LNS ' 0 D4 oRNER 0 PARKED 0 ORNERLESS ❑ FED 0 PEDAL 0 EOUES 0 NIA/ 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 / / FOR DAMAGEDAREA(S) FROM TOWED U1 .0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE lo) 2 FIRE 0 lSl 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 0 m ion ❑Y ❑N ❑UNK VEH. AT CRASH ®INT UNKNOWN 8 it ii 4 COM VI EH�� 0 ® ALGN OF CITY PLATE NO. STATE YEAR } 6 1 m F ID VIN INSURANCE CO. EXPIRED 1 -13 unknown 0 Y 0 N U2 I— EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same unknown 1 rr o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU L Same❑Y ❑" 99 G) 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PED ❑PEOSL ❑EQUES 0 NlAV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut • m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Toyota Camry 2019 00-NONE it 12 ,_+ DUE TO CRASH ❑ ® 1 .Z1 13-UNDER CARRIAGE 10 I I, s FIRE ❑ MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 ❑ MISPDR 00 Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value g 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _jl 6 ji 4 COM VEH 0 ® U1 to 1— FIRST CONTACT 5 7 0 •It Yee.See Sidebar EE14467 IL 2025 REAR O cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 BZ1 H K8KU026962 State Farm ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,MI POLICY NUMBER 8 i Pantoja Zavala. Maria.G. 3376651 SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 318 KATHLEEN DR 6. ELGIN . IL.60123 (847)915-9673 Ut = (UNIT) (SEAT) (DOB) !SEX! ISAFT) (AIR) (INJ! (EJCT! (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE! (EMS) (HOSPITAL) n I I - U2 996 r m / / - '#OCCS ' D / /• U1 1 m / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 18 5 10,05 ,2024 12 41 0 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 2 C) T 2 0 18 28 ! r ❑PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 5 a 1 ® 11 5 ARREST NAME / / El PM 0 Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM OO T 2 0 ARREST NAME r I ptil ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 00 410-DeLeon.Jessica 602 272-Bajak , , 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 . D ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i 1 INDICATE NORTH combination) or -I m BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i '. ', i -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----.....---% 1 } } i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____A____: : i , J i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, Nfor direct compensation(example:large van used for specific purpose).or i N po ( ) 4 m y < < 5 Is any vehicle used to transport anyhazardous material HAZMAT that requires placarding(example placards will be displayed on the vehicle) .Zl Not To Scale D 31871Cathleen7Dr CARRIER NAME Z ' ADDRESS 0 N . O CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . If Yes, Name on placard 0 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% 0❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Z Form Number D m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Bluevi - 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE