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HomeMy WebLinkAbout2024-00067530 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 111111111111 11111011111 1110 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO355646 u, 9 uz 1 2 4 1 Ui 2 U2 1 U199 U2 1 U1 99 U2 1 1 10 Ut 3 U2 3 *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 14 jg NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067530 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 RT20 Elgin ❑ RELATED ®Y ❑N 10 22 2024 02:15 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W SHALES ) PEDALCYCUST® [] FREE FLOW # LNS 0 DI DRIVER ❑ PARKED ❑ERNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 O ,0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH 021 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE �0 1 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 El U2 4 m ion r / ❑Y ❑N ❑UNK VEH. AT CRASH . POINT OFO 8 il� 4 COM VLEH Value ❑ ElALGN CITY PLATE NO. STATE YEAR } e 1 I- ID VIN INSURANCE CO. EXPIRED 1 Unknown ❑Y 0 N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Y Same Unknown 2 m I— o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU Fr ❑Y ®N 99 0 ®COWER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) Ward,Tristan,J. 0 o d /y2 6 2 0 6 Nissan Sentra 2010 00-NONE yr 13-UNDER CARRIAGE 1G) 12 Y DUREETo CRASH 0 ®❑ Uz 2 C v c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a 225 E SHAG BARK LN M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value NT F Ut H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR I8T COONTACT 7 Q lI 6 1,S COM VEH ❑ ® to Eyes,See Sidebar 2 Streamwood IL 60107 0 R521315 IL 0 (l,2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)504-9910 W630-8100-6212 _IL D 0 _ 3N1AB6AP8AL712504 Progressive ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Ward,TAWAN DA 15946803 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < RESPONDER 225 S SHAG BARK LN ,Streamwood, IL,60107 (773)733-8947 Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)I(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 ❑AM Did crash occur 0 Y U2 Z N ® 11 1 10/22 /2024 05 54 ®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 2 C) T 2 0 28 2 / / 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 2 Q 1 ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT O U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N 8 AM 45 2 0 ARREST NAME I / ptil ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 554 Stebbins. Blake 302 I ❑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. _ F 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. D : . I 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -< combination) or —I r r { ' Rt.?20 INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 I -! ` r r r (example'.shuttle or charter bus)-or n Not To Sots J 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 -----;-----� -i f t- transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or 03 C :_ A____: : i I : : : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, rn for direct compensation(example:large van used for specific purpose).or O L____--____4 . , : i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m 5� placarding(example placards will be displayed on the vehicle) 71 2. CARRIER NAME Z ' �"°1 ADDRESS '� N CITY/STATE/ZIP O r -- . , C MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 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 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 't N Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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