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HomeMy WebLinkAbout2024-00063977 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I Ill OIH III II 1011 lIOfl 010�110IIIIffililhI H II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY >0035..843. u, 1 U21 3 4 1 U1 4 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063977 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT S RANDALL RD ® ❑ Elgin RELATED ❑Y coN 10 07 2024 1124 ®AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m 0 /MI N E S W College ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑ERNERLESS ❑ PED ❑PEDAL ❑EOUES ❑rev ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 1 2 / J FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) , Lily, R. 2015 mo day yr Volkswagen en Jetta 00-NONE DUE TO CRASH 11_ el -1 ® ❑ 13-UNDERCARRIAGE 191• I 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 4 < 615 ROBIN RDG F ❑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 8 1� 1 4 COM VEH ❑ ® 1 0 A 3VW2K7AJ3FM409115 GEICO ®Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 4495-03-53-98 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 73 L ❑Y ®N 2 GI ®DRIVER 0 PARKED 0 ORNERLESS 0 PEE ❑PEDAL ❑EQUES 0 NUM ❑rav 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) Chamberlain,Jessica, M. D mo6 0 7 1 9 8 5 Toyota Corolla 2022 oo-NONE +c 112 s FIREETocRasH O ® Uz 2 C v yr 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPDR n E. 2020 PADUA DR F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 4 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i 4 COM VEH ❑ ® U1 F, _ CONTACT 6 7__ I©;_.5 If Yee See Sidebar C ELGIN IL 60124 0 DJ50747 IL 2025 REAR 0 CI) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)337-6266 C516-4338-5762 IL D 0 7MUAAABG5NV015279 State Farm ®Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 6505931D1313D BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m / - #OCCS D / /• 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 i ® 11 1 10/71 1024 11 24 ❑pM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1 2 0 28 18 10,71 (024 PM 0 Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ® 11 1 ARREST NAME 0 Donnell, Lily, R. 11-601-Ax 499000714 10r 71 /024 ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION!NO. ROAD CLEARANCE TIME ' ❑Utility ',3N AM 45 2 0 ARREST NAME 1 0,71 /024 12 15 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 45 499-Dirck Cameron 702 272-Bajak 11 ,26/2024 09 00 0 RA Workers present? ®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 A. l ADDITIONAL UNITS FORMS r r-----.-----; ; i ; N -� � A CMV is defined as any motor vehicle used to transport passengers or property and. 0D Noe To Scale 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z r 1 i ; i ; ; combination) or —I INDICATE NORTH .-0 I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i +. ', i I I I -! ` r r r (example'.shuttle or charter bus)-or X ----"`___-+ + ' i I I I ' conapeacreemor -! ,` f - i 3. Is designedsl5 or fewer passengers operated contract carrier transporting employees the course of theiremployent(example employee M transporter-usually a van type vehicle or passenger car).or w i_____A__...: : , : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N - — — — — for direct compensation(example:large van used for specific purpose).or O L____ ____; ; ; + i t. 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 1 I r ` placarding(example placards will be displayed on the vehicle) 11 Zml i D CARRIER NAME Z ' cn IITa2 ��° ADDRESS 0Surra1 B 0I CITY/STATE/ZIP • r , - MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. ❑ Not in Comm./Other Q r- ."-- i i I 7 • USDOT NO. ILCC NO. m , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 7) 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 CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 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 ❑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/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE