HomeMy WebLinkAbout2024-00073210 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403631249
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-0007321 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
®CITY TOWNSHIP ❑ RELATED ❑Y ®N 11 19 2024 ®AM ❑YES El NO U1 -<
1023 ST CHARLES ST Elgin06:58
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
0NAME(LAST,FIRST,M) Fors. Mary.C. mo Chevrolet Trail Blazer 2024 00-NONE 0• OI 0 DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10,1 ,,, 2 FIRE 0 I <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SYTM IN ENGAGE15-OTHER
8 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 916•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,;i�e 4 COM VEH 0 j$J 5 0
F.
ELGIN I N I L 60120 B 1 0 FIRST CONTACT 12 7 ; _5 *Yves.See Sidebar U1
Z CF26076 IL 2025 REAR
TELEPHONE
IL D KL79M RSLXM B055005 Country Preferred ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Elgin Fire Same P12A0254344 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ElN 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 NCv ❑DV
!1 9 8 7 Hyundai PALISADE 2020' 00-NONE 0. Q!•-O DUE TO CRASH 0 ❑ 2 73
o _ 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
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M 2 $ SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 0
POINT OF 8 i1 A -4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •Iryes.See Sidebar
ZJoliet IL 60431 B 1 0 CM83289 IL 2025 I O C
D
IL KM8R44HE3LU090725 Geico ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x
Elgin Fire Miller.Allison 4545-16-81-73 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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/ ,, U1 1 D
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,19 /2024 06 58 ®❑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)
2 0 05 26 11,19 /2024 O6 59 ❑PM 0 Construction
*
R 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
—a, ARREST NAME Fors, Mary.C. 11-708 1529-000192 11/19/2024 07 04 ❑PM SLMT
o U1 ® 11 1 ISICITATIONS ISSUED 0 PENDING Utility
rnN SECTION CITATION NO. ROAD CLEARANCE TIME AM- ❑
t 2 0 ARREST NAME Miller.Stephen. M. 6-303-A 1529-000193 1 1/19 /2024 07 35 [�PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1529-Audi red.Jonathan 401 272-Bajak 01 ,07/2025 09 00 ❑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 truck trailer -<
r r --I -' r INDICATE NORTH combination):or .Z-1
St?Charles?St. ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - r r r (example:shuttle or charter bus):or
I- L.___A.._.� 1023?31?Che 1ea79t
______.___ . 3. Is designed to carry 15 or fewer passengers and operated by a contract career I 0
__ - } } transporting employees in the course of their employment(example:employee X
• •transporter-usually a van type vehicle or passenger car):or co
L L.__ C
_a.._.' I I i 1 I. } 1. 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, (I)I I } for direct compensation(example:large van used for speific purose):or
U - t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I placarding(example:placards will be displayed on the vehicle). ;p
61
CARRIER NAME Z
I - ADDRESS O
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. Not To Soda ' I n
CITY/STATE/ZIP g
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --• - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 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: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE