HomeMy WebLinkAbout2024-00069191 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003647768
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00069191 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 �1
® ❑ RELATED ®Y 0 N 10 30 2024 ®AM D YES ®No u1 -<
S MCLEAN BLVD Elgin10:55
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W FLEETWOOD DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN El V ® N WITH VEHICLES INVLD DO
U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Prochnow.Jose h. P. 0 1 /
yr 13-UNDER CARRIAGE 101 O�._Z FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 0 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _
CI N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 4i,4 COM VEH ❑ 0 1 0
H F- PINGREE GROVE IL 60140-9119 0 1 0 FIRST CONTACT 12 Y ; _s *Irves.See Sidebar Ut
Z BU52321 IL 2025 E
TELEPHONE
IL D 2HG FE2F55RH559032 GEICO El ®N U2 r 1 R
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Prochnow. Melissa 6133736899 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
2 0 0 2 Audi A4 2018 00-NONE ,�_' 12.._, DUE TO CRASH ❑ ❑ 2 x
0Yr 13-UNDER CARRIAGE 10 2 FIRE ❑ El U2 C
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F 2 4 Y ❑N UNK VEH. AT CRASH 99-UNKNOWN `OistraellonValue
6 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ' 5 1',_ COM VEH
FIRST CONTACT 6 7._.Q,__5 •If Yes.See Si 0 0 Ut CO
= PINGREE GROVE IL 60140-9121 0 1 0 EU38548 IL 2025 REAR
0
IL D WAUKMAF44JA114668 State Farm ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3373474-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10,30 ,2024 10 55 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 28 99 + ❑PM, ❑Construction *
, G
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. Et.45ARRIVED TIME ❑AM ❑Maintenance U2 5
a1 ® 11 1 ARREST NAME Prochnow.Joseph, P. 11-601-Ax 298001146W t r El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
t 2 0 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
298-Lopez, Mirko 8825 272-Bajak , , ❑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.
IF 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: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or —I
Mote aroor, BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ - } (example:shuttle or charter bus):or
g;f v iP . 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- <_--------•i
is } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N
} - --; i j - } } } g po passen rs,indudi the driver,
, for direct compensation(example:large van used for specific purpose):or
~ I I ® _ t i. i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
I ` II\ Not To Scale I CARRIER NAME z
I ` I I ADDRESS O
w
I I I CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE