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HomeMy WebLinkAbout2024-00057380 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill 010 III )III IIIIIII II 11111111111111H11 101111111111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553970* u, 9 uz 1 3 4 1 U1 99 U2 1 U199 U2 1 U1 99 U2 1 1 11 U, 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 1 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00057380 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg -n N RANDALL RD El ❑ Elgin RELATED ®Y 0" 09 09 2024 07:49 ®AM ❑YES ®No U1 .( PRIVATE mo l day I yr El PM FLOW CONDITION m ^,D(]�/MI N E s w Royal Blvd 'COUNTY PROPERTY ❑Y ®" DOORING ❑y #OF MOTOR ®SLOW 2 co 02 ICJ O Y 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH NAME OF ) Kane HIT&RUN ®'' ❑ " PEDALCYCUST®N [] FREE FLOW # LNS ' 0 D4 ORNER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EOUES 0 NW 0 RDV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .0. Unknown Unknown DO-NONE 11 1s i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10 1 2 FIRE ❑ ISl < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 El U2 m 9 76-TOP 3 r PLATE NO. STATE YEAR { 6 i COM EH10 w I— ID VIN INSURANCE CO. EXPIRED 1 -13 Unknown ❑Y ❑N U2 I— EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same Unknown 1I— m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU .5 ❑Y ❑ Same" 99 0 ®COWER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 • m m / FOR DAMAGED AREA(S) FRONT TOWED Y N S NAME(LAST,FIRST,M) Richardson,Antonio,J. 0 mo3 lday yr 9 /1 9 9 1 Dodge Ram 1500(pickup) 2017 00-NONE 1t` ©�' 1 DUE TO CRASH ❑ ® ) 1: FIRE ❑ ® U2 2 v 13-UNDER CARRIAGE Xi c 10 ElSTREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 C DISTRACTED 0 SPDR C0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 E 291 W I N DSOR CT C M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 6 T_11 6 1_5 C•IOMe6 VEH SeeSideba❑ ® U1 to C Z SOUTH ELGIN IL 60177 0 3750276 IL 2024 REARf O nn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (779)207-6700 R263-0109-1081 IL D 1C6RR7LM9HS880997 Geico ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 616959449 enc ' 3 • HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER O N Same Ut 2 (UNITE (SEAT) (DOBi ISEXI (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996• 1- / - '#OCCS ' Dm / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N 1 ® 11 1 09/09 /2024 07 49 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 0 T 2 0 28 99 ! / 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz Q 1 CO 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N 8 AM 45 1 T 2 0 ARREST NAME r I ptit ❑Unknown work zone type U1 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 414-Lara, Raul 901 404-Duffy / / 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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A AD DITIONAL UNITS FORMS ; I _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 truckrtrailer -< { combination) or r , ' r INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I I d 1 -` ` r r r (example.shuttle or charter bus)-or n 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t-----;----- 4 i -t } - t transporting employees in the course of their employment(example.employee XI transporter-usually a van type vehicle or passenger car).or w i-____A____: : i . i i r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O ____-t-____1 i; . , -: i iany 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 Ja CARRIER NAME Z ' T t ADDRESS 0 4, v _ Not To Scats J N ` n Il CITY/STATE/ZIP r 'I - MOTOR CARR ID ❑ Interstate ❑ Intrastate ! HI lir- . . • El in Comm./Govt. ElNot in Comm./Other Q r-" 4-- i i I I USDO NO. ILCC NO � m XI ,• Source of above Z . MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 rn 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Gray u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE