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HomeMy WebLinkAbout2024-00060014 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 l M 111110 11111111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003557O22 u, 1 U2 1 1 1 U116 U2 U, 1 U2 U, 1 U2 1 6 U1 14 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00060014 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ®Y 0 N 09 19 2024 ®AM ❑YES ®NO U1 —< ST CHARLES ST Elgin mo /day/yr 07:46 ❑PM FLOW CONDITION m 10 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW Cl) ® ®!MI N E p W Bent St WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peoa- 0 eaves 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FROM TOWED U1 Q Hernandez Martinez. Bradle Z. Mazda 3 2007 00-NONE 12 , OUETOCRASH ® 0 NAME(LAST,FIRST,M) y- mo yr 13-UNDER CARRIAGE © I!. 2 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m M I 2 4 SY❑Y ®SNEM UNK VEH. O AT CRASH O IN ENGAGED 15-OTHER 99-UNKNOWN 016 3 ,Distraction Value ALGN 2 r POINT OF i L a �i COM VEH ❑ j$J CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR $, F. FIRST CONTACT 11 7_ 4 1 O ;—_;__5 *lIYes.SeeSidebar U1 Z Shelbyville KY 40065 0 1 0 G8A289 KY 2024 " 8 TELEPHONE KY D 0 JM1BK143871655413 Trexis Ins ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 11-16-012845201 1 1— "6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV CIRCLE NUMBER(S) U1 yr 12 _ X1 o 13-UNDER CARRIAGE t�.i :., FIRE El ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value U1 0 - POINT OF s-.. 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=5 COM•I sVEH See •Sidebar❑ 0 C to F` ---i— C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 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 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / / UI 1 D 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 43 2 City of Elgin Curb 09,19 ,2024 07 47 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 50 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v t 2 ❑ 150 DEXTER CT ELGIN IL 60120 28 99 ! ! ❑PM ❑Construction >F Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ou CI ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME CI Utility SLMT 30 t 2 ❑ ARREST NAME AM ! r ❑❑pM ❑Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 ❑AM Workers present? CI495 Sjodir.Jacob 401 275-Engelke , , ❑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. 0 i 1 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: 1. Has a weightZ rating more than 10,000 pounds(example:truck or truckrtrailer - } }-- -i-- --' r l INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C L { _ (example:shuttle or charter bus):or C cri L A l 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - . } } transporting employees in the course of their employment(example:employee transporter-usuallyvehicle or passenger car):or a van type coI aent?stC L L.__-a-_ 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 I ;-----:----; -- Uni171 - i ; } �_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D .."\ ` placarding(example:placards will be displayed on the vehicle). XI 1 Z CARRIER NAME Z 1 - __ ADDRESS O i} w 1 CITY/STATE/ZIP 0 g { - MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ` ❑ Not in Comm./Govt. ❑ Not in Comm./Other I Not To Scale 1 - USDOT NO. ILCC NO. C XI Source of above z . • m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE