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HomeMy WebLinkAbout2024-00059840 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100011111111000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X003556900* u, 1 U21 3 4 1 U1 2 U2 1 u, 1 u2 1 U1 1 U2 1 1 10 u, 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 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2024I 2024-00059840 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m BIG TIMBER RD EIin ® ❑ RELATED ®Y 0 N 09 18 2024 12:57 ❑AM ❑YES ®NO U1 -< g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT l MI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C) FOR DAMAGEDAREA(S) FROM TOWED U1 I� Bro er. Els ra. E. 0 4 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !� U2 00 1fi F 2 5 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 12 7 ; _5 *Ir ves.See Sidebar U1 Z ED47800 IL 2025 REAR TELEPHONE IL D KL77LGE2XRC055170 Chicago Insurance ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same ILV1014403-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y El 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 l uv 0 NCv 0 Dv CIRCLE NUMBER(S) U1 '1 9 6 3 Subaru Forrester 2009 00-NONE O, Qj O DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE FIRE ❑ ® U2 C c M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il��:- 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 Y _, .5 •(ryes.See Sidebar H ELGIN IL 60123 B 1 0 AG21540 IL 2025 I 0 C M IL D JF2SH61619H709088 State Farm ❑y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same J061692C2813 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAPT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 09,18 ,2024 01 17 ®PM AM in a Work Zone? ®N DIRP D co 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 0 2 99 + , ❑PM• El Construction R , 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 ou ® 11 4 ARREST NAME Broger, Elspra, E. 11-901 1506-277 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility 45 t 2 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 % El 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1506-Nunez, Maria 501 334-Fries 10 ,08,2024 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. 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 -< �____r____; INDICATE NORTH combination):or —I QI I ® BY ARROW 2 Is seaodesigned to transport more than 15 passengers'Kluding the driver C to I NotToswe (example:shuttle or charter bus):or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O ac I I } } } transporting employees in the course of their employment(example:employee X BIOTTIMBERTRD i woo transporter-usually a van type vehicle or passenger car):or C L L.___a__-_J 1/4. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y - - - - - - - - } } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L __ ' ___; 2 UNIT . zr < < < L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ,Zmt CARRIER NAME Z i ADDRESS O T. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------4. 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO. Redmons/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 ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE