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HomeMy WebLinkAbout2024-00066321 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III (III III ll II 111111111111111111H1 IIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00359062& u, 1 U21 1 1 1 U1 5 U2 1 Ut 1 U2 1 U1 1 U2 1 1 10 Ut 4 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066321 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '�7 WING ST Elgin ❑ RELATED ®Y ❑N 10 17 2024 07:54 ®AM ❑YES ®No u1 -< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W N WESTON ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0 NIN ❑ace 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGED AREA(S) FRONT TOWED U1 0 , BRAN DON,J. 1 0 / 0 9 J 1 9 8 3 Hyundai Entourage 2007 00-NONE 11 iO 10 .,0DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 1 z FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m 8N546 MCLEAN BLVD M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN 1.' CITY PLATE NO. STATE YEAR POINT OF 6 COM VEH 0 ® 1 n FIRST CONTACT 1 7_ ? 5 ^Yves,See Sidebar U1 O Z KNDMC233376035505 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 0266545SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑N 2 17 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 KW ❑soy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m 5 0 4 / 0 9 /1 9 9 2 FOR DAMAGED AREA(S) FRONT TOWED CRASH Y N —1 r NAME(LAST,FIRST,M) Jackson,Sarah,A. mo day yr Nissan Rogue 2012 00-NONE 11 is 1 ❑ ® 2 v 13-UNDER CARRIAGE o 1 I: 2 FIRE ❑ El U2 C l STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER O9 16-TOP 3 a 7N366 ROUTE 31 F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O •Distraction Value 0 HCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 U Cl6 5 C•IO�VEHSee Sideba❑ INUI Z SOUTH ELGIN IL 60177 0 CX53069 IL 2025 " 0 CCi) D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)346-2256 J250-7819-2702 IL D JN8AS5MV9CW416913 AMICA MUTUAL ❑y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 95011221 LB BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑ N Same U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS 8 WITNESS ONLY (NAME'HADDRESS)((TELEPHONE) (EIdSI (HOSPITAL) - 1 4 02 /1 8/2021 F 12 3 0 1 Lotus M. Fisher/8N546 S MCLEAN BLVD,South Elgin,IL,60177 996 r (630)940-5164 - U2 m / / #OCCS y / / u1 2 m / 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 1 ® 11 4 10/17 /2024 08 23 ❑pM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: 0 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 3 ai 1 2 0 2 99 ! / PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 3 Q CO 11 4 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 'd NIIAM 35 2 ❑ ARREST NAME r / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1543-Sturgeon, Kyle 601 - / / ❑❑PM Workers present? ®N U2 35 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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A 0 ADDITIONAL UNITS FORMS ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z r • ; i 'r i- r r , , i INDICATE NORTH combination).or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! i. ._ ' ' ', ', ' f ` r r r (example'.shuttle or charter bus)-or n S ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . ❑ Yes 0 No ❑ Unknown A 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 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 Blue Black - 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE