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HomeMy WebLinkAbout2024-00059095 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi IIIIIII II 11111111IllIllHl 101 1101011 110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3555528 u, 1 U2 1 1 1 Ui 5 U2 1 U, 1 U2 UI 1 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059095 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m1687 MAPLE LN ❑ Elgin RELATED ❑Y coN 08 16 2024 01:00 ❑AM ® ❑YES NO U1 -( PRIVATE mo l day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ❑SLOW 1 N ❑ FT/MI N E S W 'WITH VEHICLES INVLD ElSTOPPED U2 —I O AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IM N PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ MD ❑PEDAL ❑EOUES 0 NMV ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 3 / 0 2 /1 9 9 9 FOR DAMAGED AREA(S) FRONT_ TOWED U1 0 NAME(LAST,FIRST,M) ,Jesus mo day yr Chevrolet Silverado 2007 00-NONE ii O1 , DUE TO CRASH 0 ,3-UNDERCARRIAGE ��I I 2 FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m 1687 MAPLE LN 2 M ❑Y ESYlM DUNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF & {I 6 ii 4 COM VEH 0 El 1 00 a ~ 1GCHC29G17E182553 Unknown ❑Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El ®N 2 G) ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NlAV ❑Ncv 0 DV DATE OF BIRTH CIRCLE NUMBER(S) U1 MAKE MODEL YEAR m m / / FOR DAMAGEDAREA(S) FRONT TOWED Y N s Dodge Journey 2016 00-NONE tt. j'_t DUE TO CRASH ❑ DA 2 —I , NAME(LAST,FIRST,M) mo day yr ©, Z1 c 13-UNDER CARRIAGE 10 1: 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR 0 ❑Y ® N 'DUNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 - POINT OF cgiN CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ H FIRST CONTACT 12 7__.1 a ._S •fryer,,See Sidebar Q606536 IL 2024 REAR 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3C4PDDBG2GT100831 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Comerer.Sara. E. 6164639301 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1687 MAPLE LN 5, ELGIN - IL-60123 (773)663-8886 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 0 / I - U2 996 1— m / / - #OGCS D / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N 1 ® 18 5 09/15 /2024 09 19 ❑pM in a Work Zone? El DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 3 0 T 2 ❑ 06 15 ! 1 ❑PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 1 Q ® 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME "'p N B AM 15 T 2 0 ARREST NAME 1 I ptil Ut ❑Unknown work zone type OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME • 2 2 3 0 ❑AM Workers present? ❑Y 15 558-Lara. -izette 602 272-Bajak ) / ❑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 combination) or XI INDICATE NORTHXI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. ', i .. ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 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 , 1Ee7?A1apMLn : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O L____--____; i 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) 71 CARRIER NAME T. ' t ADDRESS 0 N • CITY/STATE/ZIP 0 ' Nat To Scats i - MOTOR CARR ID ❑ Interstate El Intrastate , ( • 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. m XI , Source of above Z • . IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S ' TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D 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 BlackEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE ED ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO 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