HomeMy WebLinkAbout2024-00069804 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003f10915
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 91,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00069804 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 11 02 2024 ®AM ❑YES ®NO U1
N STATE ST Elgin08:50
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W WING ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
r'1T TOWED U1 0
NAME(LAST,FIRST,M) Van De Walker, Marlene.A. mo Toyota RAV4 2015 00-NONE 11_' Qi�OUETOCRASH El
-UNDER CARRIAGE 10 frg
i 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76•TOP 3 =
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6• it 6 j? COM VEH 0 Ea 1 00
~ ELGIN I L 60123 B 1 FIRST CONTACT 12 7 :11 _5 *IIYes.See Sidebar Ut
Z AE29712 IL 2024
TELEPHONE
IL D JTMZFREV9FD063534 Economy Premier Assurance ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 1449706440 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y ❑ N 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV
!1 9 9 4 Mitsubishi Outlander 2016 00-NONE 11_"j 12..-_1 DUETO CRASH ❑ !g 2 x
o 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6i 6 l,._.4 C.OM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 _�-_�•(ryes,See Sidebar C
ELGIN IL 60123 0 1 BC49707 IL 2024 I Si)0
IL D JA4AD2A37GZ000171 American Freedom Insuranc ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 12-2447533-00 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 10 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 City of Elgin City of Elgin street sign 11 ,02 /2024 08 50 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 150 DEXTER CT ELGIN IL 60120 17 99 11,02 ,2024 08 50 ❑PM ❑Construction >F
Z ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
®AM ❑Maintenance U2
a 3 ARREST NAME 1 1/02/2024 08 55 ❑PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT
30
t 2 ARREST NAME AM
, r ❑❑PM 0 Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 30
225 Wolek,Thomas 500 275-Engelke r , ❑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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
in
r ----r•---, , mi - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
m, N.StateTSt
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
combination):or —I
r }----r----, m - r INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or 0
E 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
- -----A---.J
- } } } transporting employees In the course of their employment(example:employee
Monttransporter-usually a van type vehicle or passenger car):or w L L.___a__ _ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y- } } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
1 Pe ( P 9 Pe or O
Link2
L----a----+ "Unit 1 I: - t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
A placarding(example:placards will be displayed on the vehicle). XI
- im CARRIER NAME Z
ADDRESS 0
D
m 0
CITY/STATE/ZIP g
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
Y ', : - 't USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes ❑ No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
0 Yes i0 No ❑ 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Bronze Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_Redmons . 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