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HomeMy WebLinkAbout2024-00067258 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill 010 III IIII III ll II 1111111111111111101111111011011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E430 u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 U1 13 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON S VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067258 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 N RANDALL RD ❑Elgin RELATED ®Y ❑N 10 21 2024 01.06 ❑AM ❑YES ®NO U1 • ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W FOX LN 'COUNTY PROPERTY El ®N DOORING El #OF MOTOR El SLOW 2 f/) ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo O PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 C) 0 5 / 0 5 /2 0 0 5 FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) ,Olivia, M. mo day yr Nissan Altima 2009 Do-NONE 11 O� , DUETOCRASH ❑ DI 13-UNDER CARRIAGE 10 I I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 6 m 6636 MAJESTIC WAY F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 I� 1 4 COM VEH ❑ ® 1 O ~ 1 N4AL21 E69C140685 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a Reynolds-Gregory, R. 1552067-SFP-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 6636 MAJESTIC WAY.Carpentersville. IL.60110 (224)760-5927 VEHU 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m 5 1 2 / 2 1 /1 9 6 5 FOR DAMAGED AREA(S) FRONT TOWED Y N —I , NAME(LAST,FIRST,M) Schutz- Richard.G. mo day yr Ford Ranger 2002 DO-NONE +t 12 , ❑ ® 2 v 13-UNDER CARRIAGE 10 j 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X a 2950 BLANCHARD LN M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN II •DistracionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COONTACT 6 7_'i Q_5 C•IO gee SidebaH r ® U1 Ca RE4R C Z West Chicago IL 60185 0 3686302B IL 2025 0 I;n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)205-5299 S320-7476-5362 IL D 1 FTYR14U92PB13015 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 0422267-SFP-13 Bnc , 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YOND N Same Ut 2 (UNIT) (SEAT) (DOB) (SEX) ISAFTI (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) 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 El U2 Z N ® 11 1 10/21 /2024 01 06 ®ppt in a Work Zone? ®N DIRP co 1 I 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 ! / 0 PM El Construction * N T 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Reynolds,Olivia, M. 11-601 1529-000160 / / El PM SLMT o U 0 CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N BAM 50 T 2 ❑ ARREST NAME / / ptil ❑Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 1529-Audi red.Jonathan 901 272-Bajak 11 / 12/2024 09 00 ❑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. _ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r____.; ; ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< combination)or r ; ' I I r INDICATE NORTH XI l I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C L } +, ', i ✓ b b I b °O °p ! ` r r r (example shuttle or charter bus) or n S t I 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----i-----• + + -r } } } transporting employees in the course of their employment(example.employee c I transporter-usually a van type vehicle or passenger car).or w :.____A____: . . , `\ © r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) 8 for direct compensation(example:large van used for specific purpose).or O L____�____� . + a' 1 i } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m P tr. placarding(example placards will be displayed on the vehicle) m Not • \ n / -I. CARRIER NAME Z 1 I I I I I / _ ADDRESS 0 To I I I 0I I CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ElIntrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. XI , Source of above Z . Form Number _ m IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 ' TRAILER VIN 1 m CA 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 Silver Redrn - 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