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HomeMy WebLinkAbout2024-00072612 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 010110 0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403645158 u, 1 U2 1 1 1 U116 U2 1 U, 1 U2 U, 1 U2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00072612 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn TECHNOLOGY DR Elgin ® ❑ RELATED ❑Y ®N 11 16 2024 ®AM ❑YES ®NO U1 —< PRIVATE mo /day/yr 00:02 ❑PM FLOW CONDITION m �O 1C.'J!MI N E s © West VANTAGE Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 21 (n Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q • NAME(LAST,FIRST,M) mo 1 9 9 3 Chevrolet Malibu 2012 00-NONE ,, 12 , OUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 1,._ 4 COM VEH 0 0 1 O FIRST CONTACT 1 7_;—_;__5 *IIYes.SeeSidebar U1 Z St Charles IL 60174 0 1 0 CL37362 IL 2024 REAR TELEPHONE IL D 1 1G1ZC5EU4CF127139 none provided ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Fleming.Shauwonta none provided 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 yr ,t_I 12 _1 ❑ ® 13 o — 13-UNDER CARRIAGE 10;1 c. 2 FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 ❑Y ElN 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 U1 0 POINT OF 8 "4 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O S �}._ COM VEH ® ❑ CO FIRST CONTACT 7 7 ._, _5 •IfYes.See Sidebar 5E0AA164 IL 2024 REAR 9 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 SEOAA164XJG035302 Greenwich Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Cassens Transport RAD943781508 BAC 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) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 11 ,16 /2024 00 02 ®❑pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 21 99 ) ) 0 PM• El Construction * Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 o121 11 1 ARREST NAME Scurlock.Olajuwaun. D. 3-707 1502000277 r r 0 PM SLMT S' N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 30 t 2 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ — ❑AM Workers present? ❑Y 30 1502-Camiacho. Fernando 901 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 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 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ I A - i. e. r ,- (example:shuttle or charter bus):or 0 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O I- �-----I----; Not 7h SoW I I I.. - } } . transportingemployees in the course of their employment pbyment(example:employee transporter-usually a van type vehicle or passenger car):or w "'"°' } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or O L l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III — — — placarding(example:placards will be displayed on the vehicle). XI cL7— D ' �® CARRIER NAME Cassens Transport ADDRESS 145 N KANSAS ST O I I , , „ i. 4. 0 CITY/STATE/ZIP Edwardsville I IL 162025 M MOTOR CARR.ID 0 Interstate El Intrastate I r Not in Comm./Govt. El Not in Comm./Other �---------- - USDOT NO. 124358 ILCC NO. rTt 73 Source of above z own tank)? 0 Yes ® No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No El Unknown A 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 ®No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gold Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE