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HomeMy WebLinkAbout2024-00057380 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III IIIOII III I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY u, 1 U2 1 3 4 1 U1 1 U2 1 U1 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00057380 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'I'I N RANDALL RD ® ❑ Elgin RELATED ®Y 0 N 09 09 2024 07:49 ®AM ❑YES ®No u1 • ,•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m I�D(]�/MI N E S W Royal Blvd 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ®SLOW 1 U) ICJ O Y 'WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N 0 FREE FLOW # LNS ig DRNER 0 PARKED 0 DRIVERLESS ❑ FED O PEDAL 0 EOUES 0 NW 0 NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 4 / 1 9 /2 0 0 5 FOR DAMAGEDAREA(S) FRONT_ TOWED Ut 0 . Bryan mo day yr 1t Mitsubishi Endeavor 2007 0o-NONE 12 , DUE TO CRASH 0 ® - E NAME(LAST,FIRST,M) IY 13-UNDER CARRIAGE t�) 2 FIRE 0 1l < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ El U2 m 504 CHEYENNE DR M SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _ PLATE NO. STATE YEAR POINT OF {I mji_ COM VEH 0 El 1 0 ~ 4A4MN21S77E068140 State Farm ❑Y ®N U2 10 . m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Trujillo,Vianey 1 091 1 566-SFP-13 1 I— t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER RESPONDER 504 CHEYENNE DR. Lake in the Hills. IL.60156 VEHU G1 L 0 Y ❑N 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 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 n NAME(LAST,FIRST,MI Havard- Michelene, R. 0 30 da0 7 2 0 0 2 Hyundai Elantra 2013 00-NONE �c 12I. s ETOCRASH ❑❑ ® Uz 2 C v yr 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 O a 999 AMBERWOOD PL F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR I8T NT COONTACT 6 7F _Il a I_5 C•IOMe6 3eeSidebarH ❑ ® U1 to PEAR C I— McHenry IL 60050 0 EH17542 IL 2025 0 fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)307-9533 H163-5560-2669 IL D SNPDH4AE5DH281796 Allstate ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 811568341 enc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y N Same Ut _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / - #OCCS ' D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 1 09/09 /2024 07 49 ❑pM in a Work Zone? ®N DIRP co T 2 ❑ I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 5 0 / / 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz Q 1 ® 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 2 0 ARREST NAME r I ptit El Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ ❑AM Workers present? 0 Y 45 414-Lara. Raul 901 404 Duffy i / ❑PM ®N U2 I 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 • ADDITIONAL UNITS FORMS ' } A CMV is defined as any motor vehicle used to transport passengers or property and 1 . r r r r , , , , . r . Z 1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer ✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I X BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` ; ; I I ; ! i. ` ' ' a. ', ' f ` r r r (example.shuttle or charter bus)-or 0 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or 03 ' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver r 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 placarding(example placards will be displayed on the vehicle) "0 1. CARRIER NAME Z ' .. ADDRESS N ' CITY/STATE/ZIP ^ MOTOR CARR ID ❑ Interstate El Intrastate < ❑ Not in Comm./Govt. ElNot in Comm./Other 0 r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m • , Source of above z #) Li Side of Truck Li Papers Li Driver H Log Book m Z GVWR/GCWR —I ❑ <10,000 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No X X m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown E D Did Carrier Safety Regulations(MCS)violation contribute to the crash% p ❑ Yes No ❑ Unknown 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 C z Form Number CJ _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 _ m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >10? m TRAILER 1 ❑ ❑ ❑ z 71 TRAILER 2 ❑ ❑ ❑ 3 u 3 COLOR u 4 COLOR TRAILER LENGTH(S)1 ft 2 't z Red Silver u 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET U 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 0 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE