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HomeMy WebLinkAbout2024-00066691 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II 111111111111111110111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X00355E405 u, 1 U21 3 1 1 U1 7 U2 1 U, 1 U2 1 Ut 1 U2 1 4 11 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 • 3 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash yR 202412024-00066691 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'n N RANDALL RD ® ❑ Elgin RELATED ®Y ❑" 10 18 2024 06:53 ❑AM ❑YES ®No u1 • ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E 5 W POINT B LV D 'COUNTY PROPERTY El 21 N DOORING ❑y #OF MOTOR ❑SLOW 15 N ❑ WITH VEHICLES INVLD El STOPPED U2 —1 El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NNV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) Feaa TOWED Ut O - BEN. 0 1 / 3 1 J1 9 8 1 Chevrolet Tahoe 2008 00-NONE ©' ..�.,D1 DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� 2IA DISTRACTED 0 El U2 2 m 1074 PINE ST 202 M ❑Y ISYNM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 . 6 4 COM VEH 0 ® 1 0 1 GNFK13068J211898 State Farm ❑Y ®N U2 m iv EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 0076025 SFP 49 1 m I— o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L ❑Y ❑" 2 0'' RESPONDER Same VEHU 73 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) Fi20 IT TOWED Y N aNAME(LAST,FIRST,m) SCHLEICHER, Lawrence. M. 1 0 0 mo v 1 9 5 2 Hyundai PALISADE 2023 oo-NONE 11 12 s REoCRASH ❑❑ ® U2 2 C v yr 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a` 792 RICHWOOD AVE M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑ Igl ElUNK VEH. AT CRASH 99-UNKNOWN • Y Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 4 COM VEH 0 ® U1 to F- FIRST CONTACT 6 Q •If Yes,See Sidebar ELGIN IL 60124 0 864362 IL 2025 is 0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)804-9216 S426-5335-2286 IL D 0 KM8R4DGE9PU565818 Crum-Halsted Agency ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 5260620800 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDERY0 ❑ Same U1 _ (UNIT) I SEAT) (DOB( (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/-(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 11 /1 5/1954 F 2 4 B 1 Q Mary E. SCHLEICHER/792 RICHWOOD AVE,ELGIN-IL-60124 Refused 996 ,- (630)804-9218 U2 m / / #OCCS D / / Lit1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 10/18 /2024 06 54 ®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 It YES check one below: U1 5 C) T 2 0 03 28 ! I 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME HUCKSTORF. BEN.J. 11-601 476000299 / / ❑PM SLMT o U CITATIONS ISSUEDPENDING • ROAD CLEARANCE TIME ❑Utility o N ❑ 0 SECTION CITATION NO. AM 50 T 2 0 ARREST NAME 10/1 8 /2024 07 31 ®PM 0 Unknown work zone type U1 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 476-Ramos.Clarissa 901 246-Kite 11 , 19/2024 09 00 0 PM Workers present? ®N U2 50 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; N _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer r 1 i i combination) or Ponl9Blvd INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. d i -` ` r r r (example.shuttle or charter bus)-or n X i3. Is i netl to carry15 or fewer passengers andoperated contract carrier0 ----?----- ( -t } ttransporting employee in the course of thir employment(example employee porter-usually a van type vehicle or passenger car).or w ' : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I ) I ( for direct compensation(example:large van used for specific purpose).or i-____-.____-; i ; , I 2 -t i. i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 t CARRIER NAME ' t ADDRESS 0 N • CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. ElNot in Comm./Other Q Not To Scale I i - USDOT NO. ILCC NO. m , 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 Form Number 0 m 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black Silver - 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE