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HomeMy WebLinkAbout2024-00067702 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIII lull 111111111111111111111110111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2234 u, 1 U21 1 1 1 U1 8 U2 1 U, 1 U2 1 u1 1 U2 1 1 12 U1 13 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067702 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 HOPPS RD ❑ Elgin RELATED ❑Y coN 10 23 2024 03'26 ❑AM ® ❑YES NO u1 • ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m ®75 ®/MI NOS S W South ) PEDALCYCUST El ® FREE FLOW # LNS 0 tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑ECUES ❑rmv ❑rrcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 1 0 / 3 1 /2 0 0 6 FOR DAMAGEDAREA(S) FRONT TOWED U1 . K. mo day yr Mazda CX5 2019 -NONE 11 1s 21 , DUE TO CRASH ❑ — 13-UNDER CARRIAGE ��r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 3 m 157 HEARTHSTONE DR M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 i' 4 COM VEH 0 ® 1 0 a ~ JM3KFBCM7K0639147 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 1008356SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El ®N 2 G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 0 / l0 J FOR DAMAGED AREA(S) Fi20 IT TOWED NAME(LAST,FIRST,M) Oliszewski.Cassandra m0 d 1 9 6 5 General MotorSi0a� 2024 00-NONE ay yr 13-UNDER CARRIAGE 11: 1$I. 1 DUREETOCRASH O ® U2 73 C 2 v 9 .?_2 c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPUR C) a` 454 MOORESFIELD ST F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEN. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 1 O T_'1 a 1_5 C•IOMe6VSee Sidebar ® U1 F- ELGIN IL 60124 0 310158913 IL 2025 I 0 CC11 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)643-4663 0422-1006-5703 IL 1GTUUDED7RZ404740 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 987881800 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same Ut 2 (UNIT) i SEAT) (DOB) (SEX) (SEPT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 06 /25/2007 F 2 3 0 1 Q Aviana R. McCollim/1131 KING ST-SOUTH ELGIN-IL-60177 Refused 996 - (847)961-8464 , U2 m / / #OCCS D / / u1 2 m / 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 23 11 1 10,23 /2024 03 26 0 pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 7 C) T 2 0 20 99 ! / 0 PM El Construction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Stone,Spencer, K. 11-708 1530000121 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AMtil ❑ 45 T 2 ❑ ARREST NAME , / pUnknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1530-Soto,Oscar 702 - 11 , 12/2024 09 00 p PM ®N U2 I 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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 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 truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or 'I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or X ; 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 M 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 ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , • • Source of above Z . ❑ Yes 0 No ❑ Unknown A 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 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N 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 Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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