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HomeMy WebLinkAbout2024-00066467 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III )III IIIIIII II 1111111111111111101111111001111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E464 u, 1 U21 1 1 1 U1 U2 U2 1 U1 1 U2 1 U1 1 U2 1 4 9 U1 1 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 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066467 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 RESERVE DR ® ❑ Elgin RELATED ❑Y coN 10 17 2024 07:cv7 ❑AM ® ❑YES NO U1 .•< PRIVATE mo /day/yr ®PM FLOW CONDITION m ��' /MI N E S W AN NA Way 'COUNTY PROPERTY ❑Y 2g1 N DOORING ❑y #OF MOTOR ❑SLOW 2 f/) . Y Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —1 0 AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 I&DRIVER 0 PARKED 0 DRIVERLESS ❑ PED O PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) mo day yr Mazda 6 2017 Do-NONE DUE To CRASH . BRYAN,A. / J ++_ is D+ ❑ ® 3 13-UNDERCARRIAGE FIRE ❑ ® 102 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ® 0 U2 m 537 E SHAG BARK LN H M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 'OislractlonValue 5 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 it ji 4 COM VEH ❑ El C) m FIRST CONTACT 1 7 :I a -5 ')ryes,See Sidebar U1 0 Z JM1GL1W59H1123462 PROGRESSIVE ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 HEINEMAN,STEFANIE, M. 983281990 1 Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 537 E SHAG BARK LN H. STREAMWOOD , IL.60107 (847)212-9787 VEHU G1 0 DRIVER ® PARKED 0 CRNERLESS 0 PED ❑PEDAL ❑EQUES 0 NUN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N Chevrolet Silverado 2000 oo-NONE 1t. j'_+ DUETOCRASH ❑ ® 1 NAME(LAST,FIRST,M) mo day yr ©, C c 13-UNDER CARRIAGE 10 I I Y FIRE El Ill U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 El SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 - H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Ojlair_ COMVEH ❑ Ca FIRST CONTACT 7 7 _5 •IfYes,See Sidebar 3065073B IL 2024 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1GCEK14T6YZ266351 STATE FARM ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I LOPEZ. EDGAR K237571-F22-13A BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 1145 RESERVE DR. ELGIN - IL.60123 (847)344-8867 U1 = IUNITi i SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS),(TELEPHONE} (EMS) (HOSPITAL) BEATRIZ BEVENTE/2413 EMILY LN ,ELGIN,IL.60123/ - 996 r W 1 2 /30/1994 F [224)241 4014 U2 m / I #OcCS y / /• U1 1 m I I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 1 10/17 /2024 07 57 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 1 C) T 2 0 41 28 ! / ❑PM ❑Construction * t N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 •® 11 1 ARREST NAME MATEO. BRYAN.A. 11-601-Ax S218000896 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N B AM 30 2 0 ARREST NAME , / ptil ❑Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 218-Wilson.Greg 801 272-Bajak 11 , 12/2024 01 30 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. 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. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1 ; i i- r r , , i i i i i INDICATE NORTH combination).or —I 3:1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! r r L ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----'-----• 1 I • : ' ' 1 1 1 i } - i• transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or 03 . i r i- 4 Is used or designated to transport between 9 and 15 passengers,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) 71 M . CARRIER NAME Z ' t ADDRESS 0 N CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not m Comm./Other Q C r-----.-----, r r r r ,-•---, i i r - DO ILCC NO. m U N XI , Source of above Z Number 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 T TRAILER 1 ❑ ❑ ❑ z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Blue•Dark Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 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