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HomeMy WebLinkAbout2024-00068061 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III )III IIII lull 11111111111111111111111111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03602272* u, 1 U2 1 3 4 1 U116 U2 1 U, 1 U2 1 ut 1 U2 1 1 11 U1 11 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1,500 ®ON SCENEEl NOT ON • 1 VEHICLE/PROPERTY ❑OVER$1.500 El AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 202412024-00068061 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 7'1 N RANDALL RD ❑Elgin RELATED ®Y ❑N 10 25 2024 10_41 ®AM ❑YES ®NO U1 • .‹ PRIVATE mo /day I yr ❑PM FLOW CONDITION m ®1 Q�I MI N E O W ROYAL Blvd COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U1 Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS O tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Nee 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 . MARILYN, P. 0 1 / 3 1 11 9 5 1 Chevrolet Equinox 2024 00-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 21 �0( 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 5 m 1339 COMSTOCK RD F ❑Y ESYl NM I UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 76-TOP 3 •DislractlonV Value ALGN I r CITY PLATE NO. STATE YEAR POINT OF a {I®ji 4 COMVEH 0 El 2 O 3GNAXWEG8RL199914 ALLSTATE ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR a Same 962970615 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L • ❑Y ❑N '' RESPONDER Same VEHU X 2 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut • m m FOR DAMAGED AREA(S) T TOWED NAME(LAST,FIRST,M) s RHEIN- NICHOLAS,J. 1 1 / 0 7 J 2 0 0 6 Ford Edge 2014 00-NONE t3-UNDERCARRIAGE It.FRONT _t DUE TO CRASH ❑ ® 2 73 ©, ✓ mo day yr c 10 Ij FIRE ❑ ® U2 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 C DISTRACTED 0 ® SPDR C) a 1148 MAGNOLIA WAY M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® El UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RI8T NT COONTACT F 12 7_1 a �' _5 •CIOMe6VSee Sidebar ® U1 ZCAROL STREAM IL 60188 0 ZX53559 IL 2025 REAR 0 fCn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)492-2782 R5006300 IL D 0 2FMDK4AK7EBB45184 GEICO ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I OPLAWSKI. FRANK 4484491271 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < DyRESPo0NR 1448 MAGNOLIA WAY.CAROL STREAM . IL.60188 Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) )INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)i(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) n I / U2 996 r m / #OCCS ' D / /• U1 1 73 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 1 ® 11 1 10,25 /2024 10 41 ❑pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME DAM It YES check one below: u1 1 C) T 2 ❑ 15 99 ! / 0 PM ElConstruction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM ❑Maintenance uz Q El 11 1 ARREST NAME / / ❑PM 0 Utility SLMT O U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 50 T 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 50 244-Blomberg. Michael 602 272-Bajak I / p 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. ^ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' Z} A CMV is defined as any motor vehicle used to transport passengers or property and r- -r----n 1 1 r r r r r 1 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1- 1 ; i r r , i i INDICATE NORTH combination).or —I 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L I ', ! i L ., ' '. ', ' I ` 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 -----'-----• + + • : ' ' 1 1 1 i } - t transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or 03 ' i 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 2 ' t ADDRESS 0 N CITY/STATE/ZIP 0 ^ MOTOR CARR ID ❑ Interstate El Intrastate < ❑ Not in Comm./Govt. ❑ Not m Comm./Other O ---- ----, r r r r r----, ir USDOT NO ILCC NO. m , Source of above z . 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 cn LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Black 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