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HomeMy WebLinkAbout2024-00057885 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011000110111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO035.48909 u, 1 U21 1 1 1 U1 4 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 15 u, 1 U214 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00057885 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 601 COOPER AVE Elgin07:23 ® ❑ RELATED 0 Y ®N 09 10 2024 ❑AM ❑YES ®NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m _ COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn ❑ FT/MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I &RUN ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Galloway.Clifton 0 8 / yr 13-UNDER CARRIAGE ©10,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it 6 ii,4 COM VEH 0 j$J 2 O m I . ELGIN I L 60120 0 1 FIRST CONTACT 11 7_:, -__5 *II Yes.See Sidebar U1 Z AY90615 IL 2024 REAR TELEPHONE IL D 5N PE24AF8J H707426 State Farm ❑Y Il N U2 Si , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Baldwin. Mary.A. 1384624-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 Nov 0 NOV 0 Dv CIRCLE NUMBER(S) U1 '1 9 9 0 Jeep(after 196g)ind Cherokee 2014 00-NONE 'o,1 t2 c,�2 DUE O CRASH 0 ® U2 2 C o mo 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistraclIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 I!t.„4 COM VEH D ® U1 CO FIRST CONTACT 5 7 _,SOS F.(ryes.See Sidebar ELGIN I L 60120 0 1 AV 18327 I L 2024 REAR Z IL D 1 C4RJ FDJ7EC498102 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same G609080C1913A BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 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 5 09(10 l2024 07 23 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 ❑ 28 99 N 3 ❑ CITATIONS ISSUED 0 PENDING • ( ( _ 0 PM- ❑Conslrtiction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / ❑PM ' o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT t 2 ❑ ARREST NAMEAM 7 ( / ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ID ❑AM Workers present? ❑Y 05 1529 Audi red.Jonathan 201 / / ❑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••--, , I % A CMV is defined as any motor vehicle used to transport passengers or property and: Z �____r____; I _ 1 Has atioeign):htratingmorethan10,000pounds(example:truckortruckrtrailer 1. -< INDICATE NORTH ,1M1 r`r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or X i i i Cooper?Ave. 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O }-----;----; p / I ` - } } } transportingemployees In the course of their employment pbyment(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 C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or L L--_-a-___� r �- i. < i. .. 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m LTi—i� placartling(example:placards will be displayed on the vehicle). XI . CARRIER NAME Z w ADDRESS T. Not To Scale i CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other i- ---"-1 - % % % % USDOT NO. ILCC NO. m XI Source of above z ' . IDOT PERMIT NO. WIDELOADo ❑Yes 0 No = 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 Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ 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