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HomeMy WebLinkAbout2024-00059355 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III HI IIIIIII II II 11111111111111H11 1011111 100 1111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553954 u, 1 U21 2 4 1 U, 3 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *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 14 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00059355 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 PARK ST El ❑ Elgin RELATED ®Y 0 N 09 16 2024 03:17 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W N G I FFOR D ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) P a1T TOWED Ut O g mo day yr 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 ® U2 2 m 617 LINDEN AVE M SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER j COM VEH 0 r CITY PLATE NO. STATE YEAR POINT OF 6 FIRST CONTACT 12 7_.; 4 El1 0 Q:_.5 ^Y Yes,See Sidebar U1 Z 1 HGCP2F33BA065445 farmers insurance ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 195594081 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L El ®N 2 17 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 NOV ❑Nov 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m S J FOR DAMAGED AREA(S) fi20 lT TOWEDT NAME(LAST,FIRST,M) Miller, Patricia,A. 0 /mo ld r yr 1 9 5 0 Honda Civic 2015 00-NONE Q O DUE CRASH 0 2 v I© UNDER CARRIAGE rp 1 2 FIRE ❑ 21 U2 Xi c c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR (7 SYSTEM IN 0 ENGAGED Q 15-OTHER 9 16-TOP 3O 9 0 X E. 155 S G I FFORD ST F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN %•Distraction Value N to CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COONTACT 5 7_ 6 OS Clfve6M V See SidebaEH r❑ C ® U1 ELGIN IL 60120 0 GPA14 IL 2025 REAR 0 ((I M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)697-3370 M460-6815-0617 IL D 0 2HGFB2F94FH504756 Twin City Fire Ins ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 83PH526362-511859 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y NR Same Ut = (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - #OCCS y / /• U1 1 73 Ito 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 u ® 11 1 91 /6/ /024 03 34 ®pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 3 2 ❑ 2 23 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑ ❑AM Maintenance uz 5 ® 11 1 ARREST NAME Reyes, Regino 11-1204-B S1519-000187 / / El PM SLMT p U ❑CITATIONS ISSUED El PENDING • SECTION CITATION NO. ' ROAD CLEARANCE TIME ' 0 Utility N AM 30 2 ❑ ARREST NAME 9/ i 6/ /024 8 PM ❑Unknown work zone type Ut T 2 2 3 ❑ • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1519-Bae2a.Guadalupe 201 246-Kite 11 / 12/2024 09 00 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 ; _r } 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 1 i i combination) or —I INDICATE NORTH XI I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', 1 i I -! ` r r r (example'.shuttle or charter bus)-or r7 [..f ---- ----1 4t 1 I t } itransporting 15 or fewer the course of their employment(example�emaployeerier 0 3. I s } transporter-usually a van type vehicle or passenger car).or w i.____A____: : tAYr 1 : 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____-L____; . 1 —II fGT - i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m I - ` placarding(example placards will be displayed on the vehicle) XI Net 7e Scab I )> CARRIER NAME I ADDRESS 0 CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , 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 El 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 Gray Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO- SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE