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HomeMy WebLinkAbout2024-00075986 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets HUI III 0 )fall DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV u, 1 U21 1 1 1 U, 4 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00075986 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l ® ❑ RELATED PRIVATE ❑Y ®N 12 03 2024 El AM ❑YES ®NO U1 -< N RANDALL RD Elgin mo /day/yr 05:44 ❑PM FLOW CONDITION M • �O 1C.'J/MI O E S W FLETCHER Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 3 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Hi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM S filer. Mar aret.J. 0 8 / yr 13-UNDER CARRIAGE ©1 ! 2FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 rr1 F 2 SYTM IN ENGAGE15-OTHER 5 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 76-TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i:�S _4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 12 7_ —__, _5 *II Yes.See Sidebar U1 V Z Sleepy Hollow IL 60118 0 1 0 CT93903 IL 2025 REAR TELEPHONE IL D 4S4GUHT63R3812918 PROGRESSIVE ❑Y ®N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 910189828 4 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 NOV ❑DV /1 9 9 3 Ford Club Wagon E350 2017 00-NONE 'o,I t2 (,�2 FIRE DUE O CRASH 0 ® U2 21 C o yr 13-UNDER CARRIAGE F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 4 POINT OF S i 4 COM VEH ® ❑ U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O,�_QI�S •IfYes See Sidebar C Palantine IL 60067 0 1 0 423318D IL 2022 i0 N IL 1FDRS9ZV7HKA32492 ACE AMERICAN ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire FL TRANSPORTATION ISA H10765924 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONEI (EMS) (HOSPITAL) U2 m ##OCCS y / / 71 / / U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,03 /2024 05 44 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) v 2 ❑ 11 28 12,03 /2024 05 49 ❑PM ❑Construction >E R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J ®AM ❑Maintenance U2 o ® 11 1 ARREST NAME Spiller. Margaret.J. 11-601 W1546-000033 12/03/2024 05 56 ❑pM SLMT o N - ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM U, 45 t 2 ❑ ARREST NAME 12/03 /2024 06 35 MPM ❑Unknown work zone type n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 D 1546 Ignacio. Patricia 901 272-Bajak / ❑❑PM Workerspresent7 ®N U2 45 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 J 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 }-- as°•; _ combination)or -I--r----, r INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 - } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-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, Pe ( P 9 Pe or 0 L l. l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires i placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME FL TRANSPORTATION INC Z ADDRESS 7701 LEGACY DR T. cn CITY/STATE/ZIP Plano I TX 175024 z 2 MOTOR CARR.ID 0 Interstate 0 Intrastate r ❑ Not in Comm./Govt. 0 Not in Comm./Other �"--- ----1 - USDOT NO. ILCC NO. m XI Source of above z . GVWR/GCWR m ❑ <10,0oo 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes ® No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes ® No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown 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 LOCAL USE ONLY TRAILER VIN 2 m v 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. Z Green White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE