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HomeMy WebLinkAbout2024-00067974 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 OIl III HI IIII lull 11111111111111111111 10111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0036O2252- u, 2 U2 1 3 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 5 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067974 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 -1'1 BIG TIMBER RD ❑ Elgin RELATED ❑Y coN 10 24 2024 07:25 ❑AM ® ❑YES NO u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 Q(]� • COUNTY PROPERTY ElY ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 N ® CJ/MI O E S W North Mclean ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ❑ FREE FLOW # LNS 0 DA ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑say ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n FOR DAMAGED AREA(S) FRONT TOWED U, O 0 1 / 0 4 J 1 9 9 9 Chevrolet Trail Blazer 2023 00-NONE /�DUE TO CRASH NAME(LAST,FIRST,M) .Cheyanne, F. mo day yr " 0O El ,3-UNDERCARRIAGE FIRE ❑ ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� 2 DISTRACTED 0 El U2 5 m 303 E 1ST ST F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 . 6 4 COM VEH 0 ® 1 0 ~ KL79MUSLXPB162014 No Insurance ®Y ❑N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same No Insurance 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 0 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NW ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N NAME(LAST,FIRST,M) Carr Hagerman, Pamela,C. 0 o 0 d6ay 1 9 y6r 4 BMW X5 2016 13-UNDE i0 12 s REocRasH ❑❑ ® U2 2 C v ,3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 1 a 504 WASHINGTON ST F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ❑ 0 MI N UNK VEH. AT CRASH 99-UNKNOWN Distraction Value - IV CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 I 4 COM VEH ❑ ® U1 to FIRST CONTACT 6 Q •IfYes,See Sidebar Z WEST DUNDEE IL 60118-1245 0 EQ87172 IL 2024 i. 0 Sn 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)477-4445 C626-6636-4699 IL D 0 5UXKR0C58G0S88493 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 0991100-SFP-13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y NR Same U1 = (UNIT( (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - #OCCS y / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 10/24 /2024 07 25 ®pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 3 2 0 28 19 10/25 /2024 07 25 co PM ElConstruction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 • ARREST NAME Acevedo,Cheyanne, F. 11-601-Ax 751653 / / ElPM SLMT c U 1 CO 11 1 ,CITATIONS ISSUED 0 PENDING • ROAD CLEARANCE TIME ❑Utility o NSECTION CITATION NO. AM 45 2 0 ARREST NAME Acevedo,Cheyanne, F. 3-707 751652 10/24 /2024 07 55 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 45 1527-Juarez,Jorge 502 334-Fries 11 /27/2024 09 00 0 RAwDrkerspresent? ®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 ; _r r A CMV is defined as any motor vehicle used to transport passengers or property and. EDTx I 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z , r 1 i ; I combination) or INDICATE NORTH XI ', J 1 ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverA', i -! ` r r r (example.shuttle or charter bus)-or 0 Li J Not To Scafe I � 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----;-----• + + i OWTTM'b'rfl° J MIN -f . } - t transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i____A____: : , — — f — — r . 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____--____ . + — I s I i iany 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z Om -N c va: agrnnb.nRd ADDRESS 0■ n N • , D 15zIr?sr 11nnermRv TE]pin,?[L7emzi , , - O CITY/STATE/ZIP - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other t DO O US DOT NO. ILCC NO XI , Source of above Z . 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 X1 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 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White White u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO ,Arties/Impound Lot Garage 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