Loading...
HomeMy WebLinkAbout2024-00064258 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets lli N IIII III 1111101lIOflHIII10101 H II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003579363. u, 1 U21 2 4 1 U1 3 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *P 0119* 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 2 El NOT ON S VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash YR 2024I2024-00064258 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 '11WESTFIELD DR ❑Elgin RELATED ®Y ❑N 10 08 2024 02:41 ❑AM El ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT I MI N E S W CAPITAL ST 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 15 Co ❑ WITH VEHICLES INVLD El STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑CRNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 FOR DAMAGED AREA(S) fa TOWED Ut OFRONTFRONTBennett, Linda.C. 0 4 / 1 3 J1 9 3 8 Nissan Murano 2015 00-NONE ©' .. '�.,D1 DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� 2 DISTRACTED 0 10 IA U2 3 m 3322 BLUEJAY LN F SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0D 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value ALGN I THER r CITY PLATE NO. STATE YEAR POINT OF 8 i. • 4 FIRST CONTACT 12 7_.i 6--:__5 ^COM VEH 0 ® 4 0 "2 5N1AZ2MH2FN271946 Lundstorm Ins ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 5455499803 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G0 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m FOR DAMAGED AREA(S) R20IT TOWED Y N n NAME(LAST,FIRST,M) Bertany.Allison, R. m0 7 / /0 day yr 0 6 1 9 8 5 Hyundai PALISADE 2024 00-NONE 1tr 1$ '_+ CRASH 0 ® 2 13-UNDER CARRIAGE 101 FIRE El ® U2 c XI c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) z DISTRACTED 0 ® SPDR 1) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3O 0 X N ❑Y ® El 314 BUFFALO DR F N UNK VEH. AT CRASH 99-UNKNOWN //�� Dist8 ractianValue - CITY STATE ZIP INJ EJCT EPTH PLATE Na STATE YEAR POFIRST CINT OFONTACT 5 7_;{_V-OS Clrve6VSee Sidebar❑ IN U1 C ELGIN IL 60124 B AC68188 IL 2025 &AO 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)404-1146 B635-0168-5792 IL D 0 KM8R3DGE7RU654616 State Farm Ins ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 3392782SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT) I SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME!,(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 03 /1 7/1932 M 2 4 0 1 0 Philip Bennett/3322 BLUEJAY LN.Woostock.IL.60098 996 r (847)715-8189 , U2 m / / #OCCS D / / UI 2 m / 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 ® 1 1 4 10/81 /024 02 41 ®pm in a Work Zone? El DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 1 C) T 2 0 23 28 ! I 0 PM El Construction * N ' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. I EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 ARREST NAME Bennett, Linda.C. 11-1204-B 465-373 / / ❑PM SLMT 1 ® 11 4 • ❑Utility p u CI CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 465-Dorado.Ariana 901 - 11 , 19/2024 01 30 ®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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transportproperty and.passengers or D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i i combination) or —I INDICATE NORTH 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 ----'-----% J I -t i } t porong employeeslin the courseaof theiremployment(example�emaployeerier OM 3. I s 03 } trans Vansporter-usually a van type vehicle or passenger car) or we.ardmrLI_ r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O uM¢ i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires in yplacarding(example placards will be displayed on the vehicle) Zml 1 um ! i CARRIER NAME Z I= ADDRESS '� N Not To Scale , CITY/STATE/ZIP r , , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. Not in Comm./Other r , USDOT NO. ILCC NO. , 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 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 Blue BlackEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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 ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE