Loading...
HomeMy WebLinkAbout2024-00067438 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 111111111111 111110111111 11111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E472' u, 1 U21 1 1 1 U1 99 U2 1 U1 1 U2 1 U1 1 U2 1 1 12 U1 13 U2 1 *PO 1 1 9* 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 • 9 EI NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067438 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 'F'I N RANDALL RD ❑Elgin RELATED ❑Y coN 10 22 2024 09:51 ®AM ❑YES ®No ut ,< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W BIG TIMBER ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nav ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O .Charleen 1 1 / 0 2 J 1 9 3 6 Buick Encore 2014 00-NONE 11 1 DUETO CRASH ❑ fgj NAME(LAST,FIRST,M) mo day yr 12 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D O DISTRACTED 0 10U2 4 m 232 TOLL VIEW TER F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN S 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF i j O COM VEH ❑ ® 1 n r' ❑ KL4CJBSBXEB599323 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 0891341sfp13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 0®DRIVER El PARKED 0 DRNERLESS ElPED ❑PEDAL El EDUCE 0 NUN ElNcv 0 Du DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / 1 J FOR DAMAGED AREA(S) Fi20 IT TOWED Y N 5 NAME(LAST,FIRST,M) Johnson,Jessica, L. Qmo day 1 9 8 7 Hyundai Elantra 2013 00-NONE ®O' 12 y ❑ ® U2 DUE TO CRASH ❑ ® 2 v 13-UNDER CARRIAGE 0) ! 2 FIRE C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR SYSTEM IN ENGAGED 15-OTHER 9 1,6-TOP 3 0 E 612 EDWARDS AVE F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N ©1 ll 4 COM VEH 0 ® U1 to CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST OF 99 Q� 6 S 'byes,See Sidebar Z WEST DUNDEE IL 60118 0 AB78405 IL 2025 I 0 (C/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)421-7575 J525-4328-7706 IL D SNPDH4AE7DH278219 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Same 0864517sfp13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same U1 = (UNIT) i SEAT) (DOB) (SEX) )SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'/-(ADDRESS)/(TELEPHONE' (EMS) (HOSPITAL) 1 3 03 /20/1966 F 2 4 0 1 Elizabeth E. Foulk/36W055 HICKORY HOLLOW DR,Dundee,IL,60118 996 r (847)833-0486 U2 m / / #OCCS D XI / / u1• 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 11 1 10,22 /2024 09 51 ❑pM in a Work Zone? ®N DIRP 5 co 1• r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 C) T 2 El 20 40ID AM / / 0 PM ❑Construction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz ® 11 1• ARREST NAME Carlsen,Charleen 11-709-A 1545000020 / / ❑PM SLMT o U ❑CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N 8 AM 40 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 40 1545-VanEycke, Brier 901 272-Bajak / / ❑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 ' } 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------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----, '- 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? ❑ 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Red 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