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HomeMy WebLinkAbout2024-00063574 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III II 0 lu II 11111111111 IIIIIIIIIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;340* u, 1 uz 1 1 1 1 u, 7 U2 1 u, 1 U2 1 u, 1 U2 1 1 10 u1 1 U2 6 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063574 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 LONGCOMMON PKWY El ❑ Elgin RELATED ❑Y co" 10 05 2024 01-33 DAM ❑YES ®No u1 -‹ PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O 00 DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑say ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 4 / 1 0 /2 0 0 2 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yr , M. Hyundai Kona 2024 00-NONE ii (12 , DUE TO CRASH ❑ Vi 13-UNDER CARRIAGE �0 I I 2 FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 3 m 3160 PEARL ST M SYM IN n ENGAGED n 15-OTHER ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN 9 76-TOP 3 ,Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 I� e l 4 COM VEH ❑ ® 1 O ~ KM8HC3AB8RU167364 unknown ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L . ❑Y ®" 2 G) ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NW ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Finneran. Edward- H. lmlo ld y6 1 yr 9 5 6 Hyundai Elantra 2016 00-NONE ;o) 12 s REo CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPCA 0 a 1056 WATERFORD RD M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distract Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 1, 4 Distraction Value VEH ❑ 21 U1 to i— FIRST CONTACT 7 Q� 6 5 •If Yes,See Sidebar C BARTLETT IL 60103 0 JUN10-BH IL 2025 0 C/j, TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)400-6424 F565-2285-6326 IL D 0 KMHD35LH5GU338337 Allstate ❑y ®N RDEF21 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 811905229 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER Same U1 = (UNIT) I SEAT) ;DOB) ISEX) (SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS),(TELEPHONEI (EMS) (HOSPITAL) 1 3 05 /26/2002 M 2 4 0 1 David E. Smith/3160 PEARL ST,ELGIN.IL.60124 - U2 996 0 (331)551 0768 - m / / #occs y / / u1 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 11 1 10,05 ,2024 01 33 ®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 0 T 2 ID 28 03 ( I 0 PM ElConstruction * c' ' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 Ei AM ❑Maintenance U2 Q ARREST NAME Walker.Austin. M. 3-707 S1507000321 / / ❑PM SLMT 1 CO 11 1 ❑Utility p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/05 /2024 02 42 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DAIS TIME present? ❑Y 30 1507-Ruiz.Alondra 801 - 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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' } 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 '. ' 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------.-----• + + • : - -, 1 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 w ' 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 ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , 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 Gray 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE