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HomeMy WebLinkAbout2024-00078659 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets lUI III H IIIl DIII 011001110110 III IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40367' u, 1 U21 1 1 2 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 5 14 U1 1 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 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00078659 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 12 15 2024 ❑AM ❑YES ®NO U1 -< N MCLEAN BLVD Elgin 08:02 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W W HIGHLAND G H LAN D AVECOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 7 / yr 13-UNDER CARRIAGE 1U 1 • 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m F 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASD 9 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 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1 Z MEETOO IL 2025 REAR TELEPHONE IL D 0 2T2BC1 BA1 FC008050 USAA ❑Y ®N U2 1-- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 011424765U 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ /1 9 9 8 Jeep(after 198;;i)ind Cherokee 2015 00-NONE O. z j-O DUE TO CRASH 0 ❑ 2 x 0 13-UNDER CARRIAGE 6 I ©Ic 2 FIRE 0 ® U2 C c M 2 4SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16•TOP 3 X 0 Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1:,-4 COMVEH ❑ ® u1 CO FIRST CONTACT 00 7�� _.5 •If Yes.See Sidebar z ELGIN IL 60123 0 1 0 BLP26 IL 2025 I 0 D IL D 0 1C4RJFAG8FC133678 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Jones. Kiera. E. 6119334578 BAG $ 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) UI 1 D / / 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12/15 /2024 08 02 0 AM 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) v 2 25 24 12,15 /2024 08 02 ®PM ❑Construction >F R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVE° TIME 1 3 ❑AM ❑Maintenance U2 - ® • 0Utility a, ARREST NAME Krenz-Snorek. Donna. E. 11-306 404000359 12/15/2024 08 02 ®PM o1SLMT U 11 1 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM Ti 2 0 11 1 ARREST NAME Marungo,Jose 6-303-A 404000360 12,15 /2024 08 27 ®PM 0 Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 494-Kirsh. Katherine 701 01 , 14,2024 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. A CMV is defined as any motor vehicle used to transport passengers or property and: Z r -- , ••--, N_ - 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -4 r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X I- <-----I-----; transporting employened to es inthe courses 5 or fewer passengers their employment ynd ment example:employeener X N?McLean7Ave. } } } 1 transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 r Unit rt. n aafi i. < i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires a o placarding(example:placards will be displayed on the vehicle). XI I D _ - -- CARRIER NAME Z ADDRESS 0 D Not To Scale I WTighianenava. w CITY/STATE/ZIP c)g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - 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 0 Yes No ❑ 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 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. 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 DUE