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HomeMy WebLinkAbout2024-00065968 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Cif 2 Sheets 1111111 OIl III I IIII lull 11111111111111111 10 1110111111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539546 u, 1 U21 2 1 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 4 10 Ut 1 U2 3 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$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) ElB Injury and JorTow Due To Crash YR 2024I2024-00065968 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 CORRON RD ® ❑ Elgin RELATED ®Y ❑N 10 15 2024 06:36 ❑AM ❑YES ®No u1 • ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W MCDONALD ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n 0 4 / 2 4 /1 9 5 5 FOR DAMAGED AREA(S) FRCNa TOWED U1 mo . M. General Motor-tterrain 2015 00-NONE ©' 12..D1 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) day yr 13-UNDER CARRIAGE FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED 0 El U2 0 m 4N593 JAMES MICHENER DR F ❑Y ®SNE❑UNK VEH. O SYTM ATCRASH D 0 15-99-UUNKNOWN THER9 16-TOP 3 Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH El El1 O FIRST CONTACT 12 7_.; 6-:_.5 'Yves,See Sidebar U1 Z 2GKFLXEK5F6306040 STATE FARM ❑Y ®N U2 21 . m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR aSame 4624350C1313D 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU 73 L ❑Y ®N 2 GI ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FROM TOWED RASH n NAME(LAST,FIRST,M) Totzke.Joshua, E. 6 1daY 1 9 yf 9 Ford F150 2015 00-NONE 1t' 12 , fffi 0 2 —Xi I v 13-UNDER CARRIAGE 10 j j 2 FIRE ❑ ® U2 C : STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a` 41W439 KREUTZER RD M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7_11 6 ., -5 COM VEH 0 ® U1 C to F. 'If Yes,See Sidebar H U N LEY IL 60142 0 3685352B IL 2025 Audi- 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)262-8803 T320-4257-9170 IL D 0 1 FTEW1 E8XFKD35353 STATE FARM ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER I I SCALETTA. PAOLO 3109467SFP13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1286 NEWPORT CIR- PINGREE GROVE , IL,60140-2070 (817)274-3811 U1 = (UNIT) /SEAT) /DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 r 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 0 Y U2 Z N ® 11 4 10/15 /2024 06 36 ®pm in a Work Zone? ®N DIRP co IN PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 2 ❑ 2 23 ! / 0 PM 0 Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q CO 11 4 ARREST NAME LONG.COLLEEN, M. 11-1204-8 51519-000196 / / ❑PM SLMT o u CITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility o N SECTION CITATION NO. AM 50 T 2 0 ARREST NAME 10/15 /2024 07 50 ®PM 0 Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ®AM Workers present? El 50 1519-Bae2 a.Guadalupe 801 - 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. 0_ 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. Tx 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer combination)or —I r ; ', ', CaarvRd r INDICATE NORTH XI I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', 1 i I -` ` r r r (example'.shuttle or charter bus)-or n X tV r Not'Po Scala � 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� -! . 1. - t transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w il ____A_ __: : .1t M DOfl' : I. 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 ____-�____1 , — - : i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires I placarding(example placards will be displayed on the vehicle) Zml CARRIER NAME Z ' I ADDRESS 0 I to '• CITY/STATE/ZIP 0 r , , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z . 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 D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID 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 Form Number 0 m 7a 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White Gray 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 I 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