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HomeMy WebLinkAbout2024-00063617 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III III 0 lu II 11111111111111011111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035T;;3 4 u, 1 U2 1 2 4 1 Ut 7 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENEEI NOT ON 1 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2O24-00063617 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 'n WALNUT AVE ®gin ID ®Y ❑N 10 05 2024 10: DAM ❑YES ®No ut ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W J EWETT ST 'COUNTY PROPERTY ❑Y ®N DOORING 0 y #OF MOTOR 0 SLOW 15 N ❑ 'WITH VEHICLES INVLD ® STOPPED U2 —1 ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑ARV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 / 2 4 /1 9 4 5 FOR DAMAGEDAREA(S) FRONT TOWED Ut . ELIZABETH. M. Buick Encore 2023 00-NONE 11 12l 0 DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 1809 GLENEAGLE CIR F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = PLATE NO. STATE YEAR POINT OF �I 6 ii_ COM VEH 0 El 1 0 KL4MMGSL6PB117645 STATE FARM ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 Same 1409201-SFP-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU L • ❑Y ❑N 2 17 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑lav 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Krueger,Joan, M. Imo day 1 9 4 1 Buick Envision 2020 00-NONE 110 I 12 '_s DUE TO CRASH 0 ® U2 2 C v 13-UNDER CARRIAGEI c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 O E. 945 SCOTTSDALE DR F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Oistrachon Value 8 1I I' 4 COM VEH 0 ® U1 to H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST OF 7 Q� 6 5 •If Yee See Sidebar PINGREE GROVE IL 60140-5423 0 JMK53 IL 2024 REAR O fCn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 K626-4934-1915 IL LRBFX2SA4LD102100 COUNTRY ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same Al2A0634443 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same U1 = (UNIT) (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) / 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 El AM Did crash occur 0 Y U2 Z N ® 11 1 10,05 ,2024 04 54 ®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 C) T 2 0 03 03 1 / 0 PM ElConstruction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 CO 11 1 ARREST NAME TOMCZAK, ELIZABETH, M. 11-710-A 402-0000737 / / ❑PM SLMT o U 0 CITATIONS ISSUED El PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N BAM 30 2 0 ARREST NAME 1 / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 402-Free, Richard 701 404-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. 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 "--r----, , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! i- t- ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi Hated to trans rt between 9 and 15 assen ers including the dr ver, 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP n , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 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% A ❑ Yes No ❑ Unknown 0 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 X1 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 >10? m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Blue Silver - 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