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HomeMy WebLinkAbout2024-00066415 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 1111111111111111101111111110111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035°356/ u, 1 U2 1 1 1 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 9 U123 U222 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066415 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 WEYMOUTH AVE ® ❑ Elgin RELATED ❑Y coN 10 17 2024 03:18 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m 0 /MI N E s w Copper ) PEDALCYCUST®N ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EouEs 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) 2016 FRONT TOWED Ut . M. „ 0 . Deborah 0 5 / 1 2 J1 9 5 2 Mitsubishi Outlander Do-NONE 12 ," DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 19) 2 FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ❑123 0 U2 2 < SYSTEM IN ENGAGED15-OTHER 9 16-TOP 3 DISTRACTED 332 WEYMOUTH AVE F ❑Y ®N ❑UNK VEH. O ATCRASH 0 99-UNKNOWN OislractlonValue 6 ALGN = CITY PLATE NO. STATE YEAR POINT OF it 6 ii 4 COM VEH ❑ ® 1 O ~ JA4JZ4AXXGZ015313 Farmers Insurance ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same A7994682730 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED 0 PEDAL 0 EQUES 0 WV ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) mo day yr Honda CRV 2022 00-NONE it 12 ,_t DUE TO CRASH 0 ® 1 c 13-UNDER CARRIAGE 10 I li 3 FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER ®16-TOP 3 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN ©, •4 •Distraction Value 9 U1 0 — POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1I I COM VEH ❑ ® C FIRST CONTACT 8 7__-1 8_5 •ItYes,See Sidebar WAC9-WV IL 2025 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5J6RT6H94NL035970 State farm ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Vuillaume, Mary,A. 0605839-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 414 BILLINGS ST- ELGIN . IL,60123 (630)360-5644 U1 = (UNIT) (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 1— m / / - - #OcCS y / / U1 1 73 Ito / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 18 1 10,17 /2024 03 18 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C) T 2 0 30 28 ! / 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Pavelka, Deborah, M. 11-1402-A W1534000078 / / ❑PM SLMT o U 0 CITATIONS ISSUED El PENDING •SECTION • CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AM 30 2 ❑ ARREST NAME / / pp1 ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1534-Santago.Jorge 801 334-Fries , / 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. r 0IF 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or 'I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '. ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or X ; 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 M 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 CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, � r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . 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? 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 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 Brown Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE