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HomeMy WebLinkAbout2024-00064208 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III OII III 101111 lIOfl 010�����III IM 111101111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;..Pr;9' u, 1 U2 1 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 15 U1 1 U2 1 *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 • 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00064208 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 ST CHARLES ST ❑Elgin RELATED ®Y ❑N 10 08 2024 09:50 ®AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y 2g1 N DOORING ❑y #OF MOTOR 0 SLOW 15 Co ❑ 'WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 AIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 ,ALLISON, M. 0 1 / 2 4 J 1 9 6 0 Nissan Rogue 2021 00-NONE ®i ©I , DUE TO CRASH ® ❑ - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m 942 SCOTTSDALE DR F SYSTEM IN ENGAGED 15-OTHER 9 >I6-TOP 3 = PLATE NO. STATE YEAR POINT OF !1 6 it_ COM VEH ❑ 0 1 0 5N1AT3BB7MC708399 COUNTRY ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 Same P010415477 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU L El Y ❑N 2 t7 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 RUM ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FROM TOWED NAME(LAST,FIRST,M) QUIrOZ, Petra 0 8 day 1 9 6 7 Jeep(after 19R&Jerokee 2008 00-NONE 11 ` 1$ ' 1 0 2XI v 13-UNDER CARRIAGE 10 i Z FIRE ❑ ® U2 C , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPOR (1 SYSTEM IN ENGAGED 15-OTHER 9 16-TppO O E. 1101 KEN N ETH CIR F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF II ONTACT 2 7. 6 5 C•lrOM VEH vee See Sidebar ® U1to C 1— ELGIN IL 60120 0 EF85783 IL 2024 REAR 0 Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)202-2142 Q625-6606-7838 IL D 1J8GR48K98C173357 SAFEWAY INS ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 Same 3954506-I L-PP003 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - '#OCCS > / /• 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 10,08 ,2024 09 55 ❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 7 2 0 2 15 ! / 0 PM ❑Construction * rri T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 Ei AM ❑Maintenance U2 Q ARREST NAME DREDGE,ALLISON, M. 11-901 402-000738 / / ❑PM SLMT ® 11 1 0 Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/08 /2024 10 38 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 402-Free, Richard 401 - 11 , 19/2024 01 30 0 PM IZI 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 and. 0D 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer combination) or INDICATE NORTH XI I I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 d i I -` ` r r r (example'.shuttle or charter bus)-or n S ---- ----% I t } itransporting employeeslin the course their employment(example�emaployeerier 0 3. I s [4.1— } transporter-usually a van type vehicle or passenger car).or w i_____A____: : , SEi r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N nrnalm _ _ 3'" r---I' for direct compensation(example:large van used for specific purpose).or 'I-tit : : O L____-_____1 , p i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m —4IK placarding(example placards will be displayed on the vehicle) 71 A :- CARRIER NAME ' I ADDRESS 0 D • . I Not To Scale . n CITY/STATE/ZIP _ Charl MOTOR CARR ID ❑ Interstate ❑ Intrastate , 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑zr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO 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 VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE