HomeMy WebLinkAbout2024-00063591 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II 010
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0Q3579854
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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 1
EI NOT ON S
VEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00063591 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
WALNUT AVE ®gin El
®'' ❑N 10 05 2024 03:16 DAM El ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W ORCHARD
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0
tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 / 1 2 /2 0 0 0 FOR DAMAGED AREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) , Matthew. D. mo day yr Nissan Sentra 2018 00-NONE 11 O1 , DUE TO CRASH El
13-UNDER CARRIAGE loI I 2 FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m
1083 COMPASS PT M ❑Y ISYNM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
CITY PLATE NO. STATE YEAR POINT OF & 1� 6 1 4 COM VEH ❑ ® 2 O
3N 1 AB7AP5JY262805 Allstate ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a
Same 811801002 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
•'' RESPONDER Same VEHU 73
L ❑Y ®N 2 G�
®cRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / /1 9 2 FOR DAMAGED AREA(S) FRONT TOWED
Williams.NAME(LAST,FIRST,M) Leondray, L. Dmo day yrKia Motors Co ul 2018 00-NONE
13-UNDER CARRIAGE is i 12 I;-y DUEFIRE TO CRASH 0
❑ [2] U2 2
2 C
v
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPUR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X
a` 655 GH I PPEWA D R 6 F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 j ! 4 COM VEH ❑ ® U1 to
H FIRST CONTACT 6 7__• ;_S •IfYes,See Sidebar
ELGIN IL 60120 B ER68735 IL 2025 R>:AR 0 CC/)
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)539-9634 W452-5327-2746 IL KNDJN2A29J7563400 State Farm ❑y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 8 i
Graves.Clarence 0152960-SFP-13 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER 1021 TODD FARM DR 1. ELGIN . IL.60123 (847)525-6185 U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
I I U2 996 r
m
- '#OCCS >
73
/ / U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z
N ® 11 1 10,05 /2024 03 16 ®pM in a Work Zone? ®N DIRP D
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7
2 ❑ 28 03 10/05 /2024 03 16 l81 PM ❑Construction *
N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
CO 11 1 ARREST NAME Monforti. Matthew. D. 11-601-Ax 1529-000122 10/05 /2024 03 26 ®PM SLMT
o U CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME 0 Utility
n SECTION CITATION NO. B qM 35
o N
2 0 ARREST NAME / / ppp ❑Unknown work zone type U1
2 2 3 CI • Am ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1529-Audi red.Jonathan 701 - 11 , 12/2024 09 00 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.
_ F 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.
0D
I 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
, r 1 i I INDICATE NORTH combination)or —I
XI
N I 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 0
ORCHARD?ST ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-----;-----� -! } } } transporting employees in the course of their employment(example.employee M
-usually a van
vehicle or
ca
�____A____: : * i r i 4a Is usedror designated to trransport between 9 and
15rpassengers,including the driver, N
for direct compensation(example:large van used for specific purpose).or
J I ` i } i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
0111C10 _ placarding(example placards will be displayed on the vehicle)
uNrr r unm_ _ — D
CARRIER NAME z
WALNUT?AVE L D
ADDRESS
• CITY/STATE/ZIP
Not To Scale MOTOR CARR ID ❑ Interstate ❑ Intrastate
00
Not in Comm./Govt. Not in Comm./Other
' C
- - USDOT NO. ILCC NO. mXI
, Source of above z
. 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
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft N
White White
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE