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HomeMy WebLinkAbout2024-00080428 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 00100 0110 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo036.72.52 u, 2 U2 1 1 1 U116 u2 u, 1 U2 U, 1 U2 5 6 u, 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-51,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00080428 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n COLLEGE GREEN DR Elgin 11:53 ® ❑ RELATED ®Y 0 N 12 24 2024 DAM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W DU FFY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 11 n FOR DAMAGEDAREA(S) FRO t TOWED U1 Q Walston. Kelse M. 0 7 / yr 13-UNDER CARRIAGE © FIRE 0 IE C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 Ea U2 m F 2 SY8 ❑Y ONM DUNK VEH. O AT CRASH IN O is-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI s 4 COM VEH 0 Ea 1 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *elves.See Sidebar U1 Z CS48816 IL 2025 E TELEPHONE IL D 0 SH H FK7H6XM U208723 State Farm ❑Y Igl N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 2401614-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 ou 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row 0 Ncv 0 DV yr 12 - C o 13-UNDER CARRIAGE 10.i t, 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-5 COM•I sVEH See •Sidebar❑ 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y. OWNER STREET,CITY STATE,ZIP .16 < RESP❑YO❑N NDER U1 = (UNIT) t SEAT I (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m Pj DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ❑ 1 3 12,24 l2024 11 53 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 g. 2 ® 43 3 19 20 ! / ❑PM. ❑Construction >F Z3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME Walston, Kelsey, M. 11-709-A 752507 ! r El Pm SLMT o u 1 0 BI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N 0 AM 30 t 2 El ARREST NAME Walston, Kelsey, M. 11-501-A-1 752506 ! r PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 3 0 ®AM Workers present? ❑Y 447-Collins, Dominique 702 11 , 71 /025 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. 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 INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or o I- "---J.-•--I '1' I - transportingdgemloyeeslin the course of 5 or fewer he r emplrs oyment(example:employee a contract ner I I ( t I ...""'"' } r } transporter-usually a van type vehicle or passenger car): r I I I ` i C 1 I I 1 } 4 Is used or designated to transport between 9 and 15 passengers,including rCjt }--- ----; .. - } } } g Po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or L L____a____a z ` - a rc.. _ l. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m _I \ placarding(example:placards will be displayed on the vehicle). X/ I I 1 CARRIER NAME Z I 1 _ __ ADDRESS 0 T. CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue,Light u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE