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HomeMy WebLinkAbout2024-00054811 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY u, 9 U2 2 4 1 Ui 1 U2 U, U2 UI 1 U2 1 13 Ui 21 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 2024I2024-00054811 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71 N COMMONWEALTH AVE ® ❑ Elgin RELATED ®Y ❑" 08 29 2024 05:53 ❑AM ❑YES ®No u1 -< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W LAWRENCE ) Kane HIT&RUN ®Y ❑ N PEDALCYCUST®N 0 FREE FLOW # LNS 0 ❑DRIVER Ig PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑CORES 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 / / FOR DAMAGED AREA(S) FRONT TOWED U1 0Volkswagen Routan 2009 00-NONE '0.,0 DUE TO CRASH ® ❑ - NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 z FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED OTHER DISTRACTED 0 ® U2 m 9 16-TOP 3 PLATE NO. STATE YEAR POINT OF j 6 COM VEH 0 ® 1 0 ID VIN INSURANCE CO. EXPIRED 2V8HW64X19R517469 None ❑Y ®N U2 I- 1.1 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a r 99 9 Gonzalez,Cesar None 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o 0 YONDE J N 303 N COMMONWEALTH AVE. ELGIN . IL.60123 (224)202-4713 VEHU > ❑DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N fi 1 DUE TO CRASH 0 0 —1 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 XI C c 13-UNDER CARRIAGE 10 j I 2 FIRE ❑ ❑ U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0 ❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 ^Distraction Value U1 0 - POINT OFto N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 9 I-5 CIO VEH Sidebar❑ ❑ C H �� • Cl) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < DYO0NR Ut I (UNITE (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r M I I - '#OCCS > / / U1 O D I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 11 1 08,29 ,2024 05 53 ®pm in a Work Zone? El DIRP co I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 0 a T 2 ❑ ! , 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 Q ARREST NAME / / 0 PM SLMT o U 1 ID 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N B AM 30 2 El ARREST NAME , , ptit ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 0 0 AM Workers present? ❑ 485-Quintana.Josue 601 334-Fries , , 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. , r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 0 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z "--r----, , 4 r r r r r , , , , . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r i ; i i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ I ', ! t- t- '- ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or 03 ' r i 4 Is used or desi Hated to trans rt between 9 and 15 assen ers including the dr ver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) .Z1 I. CARRIER NAME Z ' ADDRESS 0 D f/1 • • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r r•---, r '- DO ILCC NO. m U N XI , Source of above Z . ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z RedEn - U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO © DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage 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