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HomeMy WebLinkAbout2024-00067211 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 11111111111111111011111101111111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E429' u, 1 U2 1 1 1 1 U1 4 U2 1 U, 1 U2 1 U1 1 U2 1 1 9 U1 1 U221 *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 1 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067211 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 -1'1 BRITTANYTRL ® ❑ Elgin RELATED ❑Y coN 10 21 2024 08:52 ®AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ❑PM FLOW CONDITION m 1 0(]� COUNTY PROPERTY El 21N DOORING 0 Y #OF MOTOR ❑SLOW 1 N ® �Cl/MI N E O W Ellot TrI WITH VEHICLES INVLD El STOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 0 8 / 0 8 /1 9 8 7 FOR DAMAGED AREA(S) FRONT TOWED U1 , Darlene.V. Dodge Durango 2019 00-NONE „ D DUETOCRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 1z © UNDER CARRIAGE 10 2 FIRE ❑ ® < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m 1449 ELIOT TRL F ❑Y ISYNM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF & ij 6 4 COMVEH 0 ® 1 0 V 1 C4RDJ DGXKC780650 State Farm ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 1 99 9 Dacaynos. Norman 1290425-sfp-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER❑ 3 1449 ELIOTTRL. ELGIN . IL.60120 (224)245-7838 LIV G1 ❑DRIVER ® PARKED 0 DRIVERLESS ❑ PEE ❑PEON. ❑EOUES 0 NMV 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FROM TOWED Y N NAME(LAST,FIRST,M) mo day yr Toyota Camry 2016 00-NONE 11: 12 '_1 DUE TO CRASH ❑ 21 173 c ®13-UNDER CARRIAGE i .? 2 FIRE El MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 IN SPOR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN ©, •4 •Distraction Value 9 U1 3 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1II I� COM VEH ❑ ® C FIRST CONTACT 8 7_.1 a ._5 •It Yes,See Sidebar Z870703 IL 2025 REAR 3 PI M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 BF1 FK7GU576690 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Kim- Don, D. 0950395-sfp-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < El Y El N 215 BRITTANY TRL. ELGIN . IL.60120 (224)425-3810 U1 = (UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)l{ADDRESS)l{TELEPHONE( (EMS) (HOSPITAL) n I I - U2 996 r m / / - #OcCS y / /• U1 1 73 la / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 18 1 10/21 /2024 08 52 ❑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 1 a T 2 ❑ 1 3 17 18 ! / PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM Maintenance U2 ❑ Q ® 11 1 ARREST NAME Franco. Darlene-V. 11-601-A 321-(W)1422 / / El PM SLMT o U 0 CITATIONS ISSUED ❑PENDING •'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility "'p NIIAM 35 2 0 ARREST NAME r / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM workers present? ❑Y 35 324-Phillos.James 202 272-Bajak l / 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 " 0 ADDITIONAL UNITS FORMS ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D 4111 EWt7Tn j 1 Hasa weight rating more than 10,000 pounds(example truck or truck/trailer r I 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 I 1 0 -` ` r r r (example'.shuttle or charter bus)-or 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i.-----i_-----i 4 i -i } - i transporting employees in the course of their employment(example.employee M oorrra transporter-usually a van type vehicle or passenger car).or w :____A____: : i , : : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____L____; ; . , .1 : 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 , placarding(example placards will be displayed on the vehicle) 71 „ T. CARRIER NAME Z ' t ADDRESS 0 '. I�l 2107Drltlmry7Tr1 • (D/f ill CITY/STATE/ZIP 0 illiti MOTOR CARR ID ❑ Interstate ❑ Intrastate L) 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 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 White 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 Arties/Owners Residence SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE