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HomeMy WebLinkAbout2024-00067293 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II 11111111111111111011111111111III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003556442- u, 1 U21 1 1 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ®OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067293 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 't'1 BOWES RD ® ❑ Elgin RELATED ❑Y coN 10 21 2024 04:02 ❑AM ❑YES ®NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m 050 ®/MI N E s® Alberta Rd 'COUNTY PROPERTY ElY ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 N Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg oRNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 4 / 2 2 /1 9 6 4 FOR DAMAGED AREA(S) FRONT TOWED U1 , Lisa.S. Mazda CX5 2016 00-NONE ©' .. '�..D DUETOCRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 El U2 2 m 41W490 SILVANA DR F ❑Y ISYNM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF & ij 6 4 COMVEH 0 ® 4 0 A JM3KE4DY9G0723574 State Farm Ins ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 0495785SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L El Y ®N 2 17 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m 0 6 / 0 m / FOR DAMAGED AREA(S) FRONT DCRASH Y N NAME(LAST,FIRST,M) Yager.Courtney-m_ mo Y yr 1 9 9 0 M TO Toyota RAV4 2014 00-NONE 1t r 1$ El ® a 13-UNDER CARRIAGE 10 ! Y DUFIREETO El ® 2 Xi U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n E 2072 CONSTITUTION CT F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN -DistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRST CINT OFONTACT 5 O78 © OS Clrve6M VSee Sidebar❑ ® U1 C EH ELGIN IL 60123 B TORTAY IL 2025 REAR 0 rn TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)833-8468 Y260-1139-0762 IL D 0 JTMRFREV7EJ003753 State Farm Ins ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 2858101SFP13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NEl R Same Ut _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (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 ❑Y U2 Z N ® 11 1 10/21 /2024 04 25 ®pm 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 3 C) T 2 0 03 28 ! / 0 PM ❑Construction �} * c' 1 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 ARREST NAME Shoemaker, Lisa,S. 11-601 465-377 / / ❑PM SLMT CO 11 1 ❑Utilityp U CI CITATIONS ISSUED ❑ ' PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 50 T 2 ❑ ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50 465-Dorado,Ariana 801 - 11 , 19/2024 01 30 ®PM IZI 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 ADDITIONAL UNITS FORMS ; _� Q} A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r ; combination).or —I INDICATE NORTH xi N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 , i 1 -` ` r r r (example'.shuttle or charter bus)-or n X 6owes�f� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t-----;-----� -i } I- t transporting employees in the course of their employment(example.employee XI transporter-usually a van type vehicle or passenger car).or w i_____A____: : i : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O L ; ; ; , MISED '.p 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) .Zml j I CARRIER NAME Z ' 0 .. ADDRESS 0 ' Not To Scale CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other ' r , ^ USDOT NO. ILCC NO. ,• Source of above Z . —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 71 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown 0 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 D m XI IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z cn Gray Gray - 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