HomeMy WebLinkAbout2024-00059558 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110110001111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003556908
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00059558 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED 0 Y ®N 09 17 2024 ®AM ❑YES ®NO U1 -<
DUNDEE AVE Elgin 11:52
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W HICKORY PL COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 6 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 8 !
yr 11-. 12 1 ❑ ENE
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 <<Tl
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�B �i 4 COM VEH 0 El 1 0
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 1 7 ; __5 *llves.SeeSidebar U1
Z DY28285 IL 2025 REAR
TELEPHONE
IL D 0 2C4RDGDG9DR546528 StateFarm ®Y ❑N U2 I-
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR -1
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Same K399719D1313 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused 0 Y ® N 2 0
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 KCV 0 Dv
yr g 10;j t2 c., E FIRE ❑ ® U2 98 C
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13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.10-TOP 3 0 ® SPDR n
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 6 U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II 6 j�',_ COM VEH ® 0 CO
F,,, FIRST CONTACT 7 Q11—�L_5 •IfYes.See Sidebar
FP204813 IL 2024 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4UZAC3G77PCUP0482 Liberty Mutual ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
UNITED PARCEL SERVIC AS2C21004175334 BAc $
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)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 co
09,17 /2024 11 52 ®p PM AM in a Work Zone? ®N DIRP D
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 �
0 2 0 28 14 , ! ❑PM ❑Construction *
1
Z3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o 1 ® 11 1 ARREST NAME Kreger,James,A. 11-601-Ax 153000082 ! r El PM SLMT
I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
o N DI AM 30
r 2 El ARREST NAME Kreger,James,A. 3-707 153000083 r r PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1530-Soto.Oscar 201 272-Bajak 11 , 12,2024 09 00 0 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 truck trailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C_ } (example:shuttle or charter bus):orI- I- --I-•--; O • transportig emoloyeeslin the course5 or fewer�of�heir emrs antlyment example:employee a contract ner0 ,fini� g transporterg-usually a van Type vehicle or passenger car):or w`( �"'T". `�l • 1 } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, to. for direct compensation(example:large van used for specific purpose):or364 Dundee Ave I l. i. i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
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CARRIER NAME Z
I / ._ ADDRESS
f D
I/ CITY/STATE/ZIP I n
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ®No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®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 0 0 Z
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Brown
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Other/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE