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HomeMy WebLinkAbout2024-00066896 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111111011liii 1111 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593 32' u, 1 U21 3 4 1 U1 4 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 ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 20241 2 024-0 0 0 6 6896 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT N RANDALL RD El ❑ Elgin RELATED ❑Y coN 1 O 19 2024 08:59 ❑AM ❑YES ®No u1 ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m ®1 5�1 MI N E O W North Point ) PEDALCYCUST® [] FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑rmv ❑Rcv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 1 1 / 2 9 /1 9 4 8 FOR DAMAGEDAREA(S) FROM TOWED U1 ,Steven,A. Kia Motors Cof.�ptima 2018 00-NONE ®i 12 10 DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 FIRE 0 ISI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 4 m 301 W SPRING ST 1 M ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,OistractlonValue 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 I{ 6 II_ COM VEH 0 ISl 1 0 a 5XXGT4L39JG213192 Grange Insurancee ❑Y ®N U2Pi m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same 4437568 1 r o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU 73 L ❑Y ®N 2 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 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 NAME(LAST,FIRST,M) Swiderski, Brandon, M. mo O 8 Oa 1 yr 9 9 4 Honda CRV 2016 00-NONE +c' 12 s ReocRasH 0❑ ® U2 2 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a` 865 BUCKINGHAM PL 310 M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 j i'r 4 COM VEH ❑ IN U1 to F„ FIRST CONTACT 6 7__. •If Yes,See Sidebar Z Chicago IL 60657 0 Q689095 IL 2025 F0 Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)342-0531 S362-0739-4220 IL D 0 JTMZFREVOGJO89880 Statefarm ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 1213499SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER Same U1 = (UNITE i SEAT) ;DOB) (SEX) (SAFT) (AIR) )INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME i I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 1 08 /08/1996 F 2 3 0 1 0 Jamie Swiderski/865 BUCKINGHAM PL 310,Chicago,IL,60657 - Refused 996 1 (815)342-0531 , U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z u ® 11 1 1 10/19 /2024 08 59 ®pM in a Work Zone? El 1 DIRP D r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 T 2 ❑ 28 99 ! I 0 PM ❑Construction * r�•A T 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Williams,Steven,A. 11-601 W1500000287 / / 0 PM SLMT o UCITATIONS ISSUEDPENDING • ROAD CLEARANCE TIME ❑Utility o N 0 0 SECTION CITATION NO. AM 45 2 El ARREST NAME 10 i 19 /2024 09 02 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 45 2 2 3 ❑ 1500-Chew, Marie 901 - / / Q AM Workers present? ®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 . 4 } 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------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 CO ' 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 . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 7) 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. y White 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE