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HomeMy WebLinkAbout2024-00067705 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets I li II I111111 11I 11110HOI�DI1111111�OM��M' DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00359°106. u, 1 U21 1 1 1 U, 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 U1 18 U213 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 3 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067705 VENT * ADDRESS NO. •HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 S RANDALL RD ❑Elgin RELATED ❑Y co" 10 23 2024 03:37 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m ^,0 ®/MI N E SOW Route 20 ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg oRNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES 0 Nuv 0 rfcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 .Amy. L. 1 1 / 0 4 /1 9 7 5 Ford Explorer 2019 00-NONE „ 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE to 1 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 4 < SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 16965 EAGLE DR F / ❑Y ®N ❑UNK VEH. O AT CRASH 0 99-UNKNOWN S 4 'Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF O 6 COM VEH 0 ® 1 0 A 1FM5K8GT9KGB48443 Rockford Mutual Ins Co ❑Y ®N U2 m I! EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Same PA000007712044 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X ❑Y ®" 2 G) 5 ®cRIVER ❑ PARKED 0 CRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑RCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGEDAREA(S) TOWED RASH Y N NAME(LAST,FIRST,MI Hannen.Carrie. L. O o laay 1 9$0 Chrysler Pacifica 2018 oo-NONE It' 12 1.: 0 ® 2 73 73 v 13-UNDER CARRIAGE 10 j 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 1) E. 0S527 JEFFERSON ST F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y Igl N DUNK VEH. AT CRASH 99-UNKNOWN -OistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR IST NT COONTACT 1 7_ to 6 5 COM VEH ❑ ® U1 C • •If Yes,See Sidebar 2 Winfield IL 60190 0 K635217 IL 2025 REAR- O f/j, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)338-5915 H550-1128-0677 IL D 2C4RC1 EG9JR112782 State Farm Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 2888575-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNITE I SEAT) i DOB) (SEX' ;SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 09 /27/2007 M 2 4 0 1 0 Tyler M. Walters/16965 EAGLE DR.Genoa.IL.60135 996 r (815)701-6109 - U2 m / / #OCCS y / / UI 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N i 23 11 1 10/23 /2024 03 37 ®PM in a Work Zone? ®N DIRP D 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 20 99 ! / 0 PM ElConstruction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance U2 5 Q ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 'd N 8 AM45 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 0 AM Workers present? ❑Y 45 481-Rodriguez. Hannah 801 334-Fries / / ❑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 ' ` i I ' t ` ` ` ., ' '. ' ' ` ` 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------t-----• + + • : - 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 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r - DO ILCC NO. m U N XI , Source of above Z . Form Number _ m 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 T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray White - 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