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HomeMy WebLinkAbout2024-00057483 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III )III III ll II 111111llIllIllHlllflll 10111101101 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0O3553460' u, 9 uz 1 6 4 1 U199 uz 1 U199 U2 1 U1 99 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENEEl NOT ON 2 VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00057483 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg '1'I NATIONAL ST ❑Elgin RELATED ❑Y co" 09 09 2024 03:31 ❑AM El ®No U1 -< PRIVATE mo l day I yr ®PM FLOW CONDITION m 2340431 MI NOS w South State ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 D4 ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES 0 NIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown DO-NONE 11 12 i' , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE ��) 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 El U2 2 m ion s- / ❑Y ❑N ❑UNK VEH. AT CRASH " POINT OFO 8 il� 4 COM VI EH�� 0 ® ALGN CITY PLATE NO. STATE YEAR } e 2 F ID VIN INSURANCE CO. EXPIRED 2 -0° NIA ❑Y ❑N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same NIA 1 r o HOSPITAL(TAKEN TO) r INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 99 0 5 ®COWER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut Y N m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Small.Alayna. D. Om5 o Day 1 yr 9 9 8 Honda Civic 2007 00-NONE 1G) 12 s DUE ED CRASH 0 ® U2 2 C -2 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 0 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 3 X E 409 GRISWOLD ST F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ! 4 COM VEH 0 ® U1 C F, FIRST CONTACT 6 7_•_1 ;=5 •If Yee See Sidebar ELGIN IL 60123 0 E173526 IL 2025 REAR 0 CI) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)777-2484 S540-0049-8731 IL D 1 HGFA16847L031577 State farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 0282620-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y 0NR Same Ut = (UNIT) (SEAT) /DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - - #OCCS y / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 9 09(09 (2024 03 31 ®PM in a Work Zone? ®N DIRP CO 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: Ut 3 C) T 2 0 28 03 ! 1 0 PM ElConstruction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 3 1 CO 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type U1 T • OFFICER ID SIGNATURE • BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1534-SantIago.Jorge 701 - ( / ❑Q PM workers present? ®N U2 30 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 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. Z r- -r--- 4 , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i. L ' ' '. ', ' 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------i-----• + + • : - -, 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 w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 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) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP O , , • . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, i - DO ILCC NO. m U N XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ 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 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z White BlueEn - 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