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HomeMy WebLinkAbout2024-00067076 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III OIH III 1001101111 NH 10I1111IHUHIlHIlII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3593G21 u, 1 U2 1 1 1 1 U116 U2 1 U, 1 Uz 1 U1 1 Uz 1 1 11 U1 1 Uz 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067076 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '17 WALNUT AVE ® ❑ Elgin RELATED ❑Y coN 10 20 2024 03'08 DAM ❑YES ®NO U1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m 05O 1Cl O 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR 0 SLOW 1 N I MI N S W Griswold St 'WITH VEHICLES INVLD 0 STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) / 1 6 J FOR DAMAGED AREA(S) FRONT TOWED U1 Kia Motors Co7 ul 2013 00-NONE 13-UNDERCARRIAGE DUE TO CRASH NAME(LAST,FIRST,M) , Katrina,A. mo day yr �° 0Q D ❑ 1 l FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED 0 El U2 2 m 439 FRANKLIN ST F ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 6 ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 ® 1 0 F FIRST CONTACT 12 7 ? 6 :_.5 ^Yves,See Sidebar U1 Z KNDJT2A59D7613118 Nationwide ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR a Mcconnell.Juanita 9112J042708 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER RESPONDER 439 FRANKLIN ST, ELGIN , IL,60120 VEHU L ❑Y ®N 2 G1 5 ®DRIVER ❑ PARKED ❑CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUV ❑NCV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) GamplOrll, Danielle, F. Omo day 2 0 0 6 Lincoln M KC 2015 00-NONE yr 13-UNDER CARRIAGE tt` 12 I FIREE TO CRASH 0 ® 2 Xi I; 10 j c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 ❑ IN U2 C DISTRACTED 0 IN SPDR C) SYSTEM VIN 9 0 a 1067 CARPENTER CT F ENGAGED 9 15-OTHER 9 16-TOP 3 • X ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN Distraction Value CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 6 O7 8 '{r/-OS COM4 • gee SidebarH ❑ 21 to U, C Elk Grove Village IL 600007 0 J H P692 IL 2024 REARf 0 fp TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)501-6392 C515-1660-6685 IL D 0 SLMTJ2AH6FUJ41496 American Select Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Rubino,Carmela WNP374172C BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1067 CARPENTER CT, Elk Grove Village. IL.600007 (847)899-0506 U1 = (UNIT) )SEAT) (DOB) (SEX) (SAFT) (AIR) (IN))) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 1— m / #OCCS D / /• U1 1 m I I 1 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 10/20 /2024 03 23 ®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 3 C) T 2 0 40 28 ! / 0 PM El Construction * 1 N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑ ❑AM Maintenance uz 3 • ARREST NAME Rosenauer, Katrina,A. 11-601 494000334 / / ❑PM SLMT El 11 1 ❑Utility p U CI CITATIONS ISSUED ❑ ' PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 39 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 494-Kirsh, Katherine 701 334-Fries 11 / 12/2024 09 00 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 0 IF 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 i combination) or —I INDICATE NORTH XI 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 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 • CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, 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? ID 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 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 Green 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