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HomeMy WebLinkAbout2024-00079116 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 011 l0I 1 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003664381 u, 1 U21 3 4 1 U1 2 U2 1 U, 1 u2 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* 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 El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2024I 2024-00079116 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I N MCLEAN BLVD El in ❑ RELATED ®Y 0 N 12 18 2024 07:22 ®AM ®YES 0 NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W WING ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n f4T TOWED U1 0Lawdensk Michelle.T. Hyundai Kona 2023 00-NONE , 2 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) y- mo yr 13-UNDER CARRIAGE ©, :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn F 2 4 El ®N SYSTEM❑UNK VEH. AT CRASH 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 Ea 1 0 F. Bolingbrook I L 60496 0 1 0 FIRST CONTACT 1 7_: __5 *II Yes.See Sidebar U1 Z 9 ED22110 IL 2025 REAR TELEPHONE IL D 0 KM8K62AB1 PU048060 Selective Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Lawdensky.Jahnel. R. F5385337 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O New 0 Ixv ❑Dv /2 0 0 4 FROM TOWED RSX 2005 00-NONE „ "'12 "_, DUE TO CRASH rg ❑ 2 x o - 13-UNDER CARRIAGE i FIRE ❑ ® U2 Ti M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 6 i,.4 COM VEH ❑ 122 Ut CO F- . . FIRST CONTACT 11 7 ,__5 •IfYes.See Sidebar C ELGIN IL 60123 0 1 0 EX55473 IL 2025 RE 0 N IL D 0 JH4DC530255015384 First Chicago ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same ILS1067643-00 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (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 El 11 1 co 12/18 /2024 07 22 ®❑PM in a Work Zone? NJ N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T o� 2 ❑ 2 15 ) / ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 oEl 11 1 ARREST NAME Lawdensky. Michelle.T. 11-901-A 1529-000224 / / El PM SLMT o N ❑CITATIONS ISSUED �PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility El t 2 0 ARREST NAME AM T / / PM 0 Unknown work zone type 35 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1529-Audi red.Jonathan 601 391-Jacobucci 01 ,07/2025 09 00 0 PM Workerspresenl7 ®N U2 35 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 -< r r --I -' I. INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r r (example:shuttle or charter bus):or 0 ng a 3. Is designed tocarry15 fewer passengers and operated a contract carrier O eS or ________j f �� - } } } transporting employees In the course of their employment(example:employee X ` `---_a----; .............`. ~~ _ ' ^ili �����. _ transporter usuallyvanvehiclepassengercar):or drive a „- -y,n nspo a type or C �, } } } 4. Is used or designated to transport between 9 and 15 passengers,including the r, N — :~ — for direct compensation I van used for specificor L L--_-a-...� ' — _ 'y I. L 5 Is any vehicle used to transport any hazardous material(HAZMAT) requires O _ 'D it — placarding(example:placards will be displayed on the vehicle). XI N4Mdtean4BNd ) , - . . . . -- CARRIER NAME Z jADDRESS D Not 70 Soots f I r CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v 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 White Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/Unknown SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Aides/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE