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HomeMy WebLinkAbout2024-00061694 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III IIII IIII lull 1111111111111111 101 III 0111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003579919. u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 2 El NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061694 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '11N RANDALL RD ® ❑ Elgin RELATED ❑Y coN 09 26 2024 03'56 ❑AM ❑YES ®No u1 • ,•< PRIVATE mo l day I yr ®PM FLOW CONDITION m 050431 MI N E O W South H IGG I ) PEDALCYCUST® ❑ FREE FLOW # LNS O tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 . NATALIA. L. 0 6 / 1 5 J 1 9 9 5 Dodge Journey FOR DAMAGED AREA(S) FRONT TOWED U1 2014 00-NONE 11 l , DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo day yr 'Z 13-UNDER CARRIAGE 10 (21 I I• 2 FIRE ❑ ® 4 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m 128 ELLIS RD F ❑Y IN NSYSTEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 5 ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 {I� 4 COM VEH ❑ ® 1 O ~ ❑ 3C4PDCGB8ET311410 ALLSTATE ❑Y ®N U2 18 . m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 802967061 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) 5' ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 • m m FOR DAMAGED AREA(S) FRO TTLOiE EDCRasH a1 NAME(LAST,FIRST,M) GARCIA. BENJAMIN mo day J1 9 NT 3 day yr Chevrolet Silverado 2015 00-NONE It' 12 ' , ❑ ® 2Xi v 13-UNDER CARRIAGE 10 .. 2 FIRE ❑ IN U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 0 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 X a 4207 CR ESTWOO D ST M ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & 6 _4 COM VEH ❑ ® U1 F FIRST CONTACT 6 7--1®__5 •If Yes,See Sidebar MCHENRY IL 60050 0 1906280 IL 2024 •RFC 0 nn DTELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)308-8297 G620-0609-3352 IL D 3GCUKPEHOFG529164 STATE FARM ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 2221989SFP13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < O RESPONDER N Same Ut _ (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m /• - #OCCS ' D / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 11 1 1 09/26 /2024 03 56 ®pm in a Work Zone? El 1 DIRP co I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 C) T 2 ❑ 41 99 ! I 0 PM El Construction * N 3 0 izl CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME KUPREWICZ. NATALIA. L. 11-710-A 1535000077 / / ❑PM SLMT O U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ❑Utility o N ❑ ❑ SECTION CITATION NO. AM 50 r,f Co T 2 0 ARREST NAME 09/26 /2024 03 56 ®PM 0 Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1535-Solis. Laura 901 334-Fries 10 1 22/2024 01 30 0 pM Am Workers present? ®N U2 50 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 and. Z r-"--r----, , 4 r r r r r , , , 1 . r 0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -< ' r i ; i i i- r r , , i r INDICATE NORTH combination) or —I XI 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 X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------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 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` 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•---, i '- DO ILCC NO. m U N 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 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 m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Silver WhiteEn - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE