HomeMy WebLinkAbout2024-00063581 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111
DIII
III (III (IIIIII II 11111111111111011111111H1111
(Ill II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T7341
u, 1 U2 3 4 1 Ui 5 U2 U, 1 U2 U1 1 U2 1 6 Ut 3 U2 *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 ®ON SCENE 14
El NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00063581 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'n
N RANDALL RD ❑Elgin RELATED ®Y ❑" 10 05 2024 0219 ❑AM ❑YES ®No ut -<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W W
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER 0 PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
Honda CRV 2014 00-NONE
FOR DAMAGEDAREA(S) FRONT TOWED U, O
NAME(LAST,FIRST,M) .Gretchen.S. mo / day 2 9J yr ®I or
1 DUE TO CRASH El ❑
13-UNDER CARRIAGE 10 2 FIRE ❑ 1l <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
50 S GROVE AVE 508 F SYSTEM IN ENGAGED 15-OTHER 9 >I6-TOP 3 =
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF !1 6 it_ COM VEH ❑ ❑ 1 0
5J6RM4H58EL060711 STATE FARM ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 Same 2571207SFP13 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER Same VEHU
L ❑Y ❑" 2 0
❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEOPL ❑EQUES 0 WV ❑Nov 0 ov DATE OF BIRTH U1
MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 ❑
, NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 XI
C
c 13-UNDER CARRIAGE 10) Y FIRE ❑ ❑ U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 -
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II 6 I_s C•IOMes 3eeSidebaID C❑
1- WAR
)
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
OPOElNR U, _
(UNIT) I SEAT) i DOB' (SEX) (SAFT) (AIR) )INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME'H ADDRESS i 7{TELEPHONE) (EMS) (HOSPITAL) C)
W 05 /03/1986 M WILLIAM A BENENHALEY/ 138 BROOKEDGE DR _HAMPSHIRE.IL.60140/ r
(760)224-7691 , U2 m
/ / #OCCS D
/ / U1 1 m
I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 , ® 29 1 State of Illinois.2016-00040901 Traffic Light 10,05 ,2024 02 20 ®PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 5
2 ❑ 801 E SANGAMON AVE Springfield) 90210 06 17 / , PM
0 ❑Construction *
N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q 1 ❑ ARREST NAME Vapnar.Gretchen.S. 11-801 402-000736 / / El PM SLMT
o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N E AM45
2 ❑ ARREST NAME / / ptil ❑Unknown work zone type Ut
T --
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present?
El402 Free. Richard 700 404 Duffy , ❑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
' _ } A CMV is defined as any motor vehicle used to transport passengers or property a
r_..--•----.1 , 1 , I I I and.
Z
01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
r { ; ; IRI combination).or
INDICATE NORTH XI I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t t _ W.?NlgNend?Ava _ — _ _ _t 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
-----;-----� -t t } - t transporting employees in the course of their employment(example.employee M CO
-usually a van type vehicle or passenger car).or
, ? : I. i 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purpose).or O
L____-�____;1 i , : i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
11
Not lb Scale placarding(example placards will be displayed on the vehicle) m
71
CARRIER NAME Z
' t ADDRESS 0
To
.vr neal d (fl
•
• CITY/STATE/ZIP 0
• - MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r , USDOT NO. ILCC NO.
XI
, Source of above Z
_ 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? O
❑ 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
Form Number 0
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
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 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
White
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE