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HomeMy WebLinkAbout2024-00058222 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL •MANY u, 1 U2 1 1 1 Ui 1 U2 U, 1 U2 UI 1 U2 4 11 Ut 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00058222 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 ROUTE 20 HWY ® ❑ Elgin RELATED ❑Y CON 09 11 2024 09:49 EH,'" ❑YES ®No ut • ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m Ell 0Q MI N E S® South State ) PEDALCYCUST® 0 FREE FLOW # LNS ' O NI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUES ❑Nrw ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 3 / 0 2 /2 0 0 1 FOR DAMAGED AREA(S) FRONT TOWED Ut mo . Erik Toyota Highlander 2019 00-NONE 11 - 1 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) day yr 12 - E ©-UNDER CARRIAGE t�1 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 53 U2 m 10237 LE N OX CT M ❑Y ❑SYSNEM❑UNK VEH. 6 AT CRASHD 5 99-UNKNOWN 9 76-TOP 3 ,Distraction Value ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF & 11 at j COM VEH 0 ® 1 O c Z STDDG RFH 1 KS062490 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Ramos.Julia 2263118-SFP-13 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER y°DEN 10237 LENOX CT. Huntley, IL.60142 (224)225-5821 VEHU 0 ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m a / / FOR DAMAGED AREA(S) FRONT TOWED Y N fi i DUE TO CRASH 0 0 —1 NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 Xi C c 13-UNDER CARRIAGE 10 I I1 2 FIRE ❑ 0 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 n Y ID ElUNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1 0 - El POINT OF N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a I_s CIOMes 3eeSideba0 0 C H R • C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2CA 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 2 BAC HOSPITAL(TAKEN TO) INCIDENT IF-Y- OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPONDER YOD N Ut 2 (UNITE (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) C) / / U2 r M • / / - #OCCS D / / U1 2 m / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ®Y U2 Z N i ® 11 1 co 09/1 1 /2024 09 30 0 pm in a Work Zone? El DIRP D T 2 ❑ PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 3 C) a ! / 0 PM ®Construction * E 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 Q 1 0 ARREST NAME Scheibe. Ryan. H. 11-503-A 469002025 / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility o N SECTION CITATION NO. AM 55 2 0 ARREST NAME 09/11 /2024 11 00 ®PM 0 Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ ❑AM Workers present? 469-Taylor,Jonathan 701 10 /08/2024 01 30 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 • ADDITIONAL UNITS FORMS ' } A CMV is defined as any motor vehicle used to transport passengers or property and, . 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. ` ' ' 1 ', ' I. ` 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) M • 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 uCOLOR TRAILER LENGTH(S)1 ft 2 't z White U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY!1 DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE