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HomeMy WebLinkAbout2024-00073322 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 II ifi 1110111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00363D430* u, 1 U21 1 1 1 u116 U2 1 u, 1 1_12 1 u, 1 U2 1 4 12 u1 1 u2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-S1,500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00073322 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 51 ® ❑ RELATED PRIVATE ❑Y ®N 11 19 2024 DAM ❑YES IX] U1 S MCLEAN BLVD Elgin mo /day/yr 05:00 ®PM FLOW CONDITION M _ 00 ®/MI O E S W Fleetwood Dr COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ElSLOW 15 ' Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) FOR DAMAGEDAREA(S) FRONT TOWED U1 Q 0 Connor.Abigail. E. 0 9 / yr 13-UNDER CARRIAGE © FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 4 M F 2 SYTM 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 99-UUNKNOWN THER 0916-TOP3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� �'.4 COM VEH 0 Ea 1 n Z Geneva IL 60134 0 1 0 FIRST CONTACT 6 �_; 6 __5 *IfYes.See Sidebar U1 0 S737220 IL 2025 REAR TELEPHONE IL D 4T4BF3EK7BR138537 Geico Ins Co ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 0 Connor.William 4375842731 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 ou p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NI/v 0 Ncv 0 Dv yr 16 ii t2 ( E FIRE 0 ® U2 C o 13-UNDER CARRIAGE c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X 0 Y NJ ID UNK VEH. AT CRASH 99-UNKNOWN Oistraglon Value 1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 1,;,_ COM VEH El ® U1 CO FIRST CONTACT 2 Y.'_, -5 *If Yes.See Sidebar = ELGIN IL 60120 0 1 0 EG60220 IL 2025 REAR D IL D 1 FMCUOD71 CKC77673 Safeway Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 3912638ILPP003 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 3 3 01 / U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 El 11 1 11 /19 /2024 05 00 ®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 2 20 99 11,19 /2024 05 00 ®pM El Construction R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME 0 Connor.Abigail. E. 11-708 481000218 1 1/19/2024 05 05 Igi pM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility r 2 El ARREST NAME 1 1/19 /2024 05 30 0 PM El Unknown work zone type U1 0 AM 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 481-Rodriguez. Hannah 702 223-Hughes 12 / 17/2024 01 30 ®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 INDICATE NORTH combination):or —I ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ 3 - (example:shuttle or charter bus):or 0 ; NOT,v a N., ' , , , � 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O / ! - y } } } transportingemployees In the course of their employment' transporter- a van vehicle or gercar): (example:employee w �/i po usually type passenger car:or C L }-----}----+ - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. fn 1- 0 for direct compensation(example:large van used for specific purpose):or O L L____a..... > ( - t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m -k . , , . placarding(example:placards will be displayed on the vehicle). :t1 -----) �f ti / ® - T CARRIER NAME Z ADDRESS 0 C ./ // CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate 0 Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _..; USDOT NO. ILCC NO. m 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 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 Gray White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE