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HomeMy WebLinkAbout2024-00058874 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets ll ii Ill III 1In ll 11111111111111H11 10111111111 lID II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553958 u, 9 uz 1 1 1 1 U199 uz 1 U1 99 U2 1 U1 99 U2 99 1 9 u1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE0 NOT ON • 7 VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00058874 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 DUNDEE AVE ❑Elgin RELATED ❑Y co" 09 14 2024 10:30 ®AM ❑YES ®NO U1 ,< PRIVATE mo l day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y 0 N DOORING ❑y #OF MOTOR ❑SLOW 1 CAElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS ' O D4 ORNER ❑ PARKED ❑ORNERLESS ❑ FED ❑PEDAL ❑EOUES 0 SIN 0 NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 19 ,r 2 FIRE 0 l�l SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 0 m ion r ❑Y ❑N ❑UNK VEH. AT CRASH ®INT UNKNOWN 8 it ii 4 COM VI EH�� 0 ® ALGN OF CITY PLATE NO. STATE YEAR } 6 1 F 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 m Y r Same Unknown 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 99 GI m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL EQUES 0 NM1 V ❑NOVNCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m m / / FOR DAMAGED AREA(S) FRONT TOWED —I mo day yr Mazda 6 2005 00-NONE 1 12 ,_1 NAME(LAST,FIRST,M) DUE TO CRASH 0 ® 273 O c 13-UNDER CARRIAGE ) I! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value g U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH 0 ® C FIRST CONTACT 11 7__.1 8_5 •(ryes,See Sidebar EG57942 IL 2023 REAR g cn, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 YVH P800555M 1 1261 Kemper ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Chavez.Celeste 12AU001566041 BAG ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 226 HILL AVE. Elgin. IL•60120 (630)562-6412 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)UITELEPHONE) i EMS) (HOSPITAL) n I I - U2 996 r m / / - #OCCS ' D / /• U1 1 m / 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 ® 18 9 09/14 /2024 10 30 ❑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 7 C) T 2 ❑ 28 18 ! 1 0 PM ElConstruction * c' 3 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 7 Q 1 ® 11 5 ARREST NAME / / 0 PM 0 Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 18N8 AM 15 1, T 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 15 430-Nemtcev.Sergey 201 275-Engelke I / p 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I 1 INDICATE NORTH combination) or —I XI N' �*� BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. ', i - ` r r r (example.shuttle or charter bus)-or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----.....---% i i- } i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____A____: : 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 L____--____4 4 . , - i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI CARRIER NAME Z t ADDRESS 0 Not To Scale D N �N_ • CITY/STATE/ZIP • r , , MOTOR CARR ID ❑ Interstate ❑ Intrastate iii ❑ Not in Comm./Govt. ❑ Not inComm/Other OO : C • r , USDOT NO. ILCC NO. , Source of above Z GVVVR/GCWR ❑ <10,000 0 10,000-26,000 1=1 >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 73 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 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 ip Maroon - 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE