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HomeMy WebLinkAbout2024-00059674 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III Olfi Ifi Ill III 11111111 11111 11111111111 111111111 ill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3560943 u, 1 U2 1 1 1 1 U, 4 U216 U, 1 U2 1 U1 1 Uz 1 3 15 U1 1 U223 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059674 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'r'I WATER RD ®gin ID ❑Y coN 09 17 2024 07'46 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m 2:150 0/MI OE S W North ) PEDALCYCUST El ® FREE FLOW # LNS O tg ORNER ❑ PARKED ❑DRIVERLESS ❑ MD ❑PEDAL ❑ECUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 4 / 1 3 /2 0 0 7 FOR DAMAGEDAREA(S) FRONT TOWED U1 mo ,Annikka. P. Kia Motors Colfportage 2013 00-NONE ®i 12I , OUETOCRASH ElIA NAME(LAST,FIRST,M) day yr 13-UNDER CARRIAGE 10 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 2 m 401 COMSTOCK DR F ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 "OislractlonValue ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8• !1 6 ii 4 COM VEH 0 El 1 0 rA ~ 5XYK7CAF7PG063092 USAA ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 016204669702 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DR DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) 0 6 day 1 9 8 2 General Motors 2020 Do-NONE , DUE TO CRASH ❑ ® 2 Lundquist, Darrell-A. � �c I 12 I. _Z FIRE ❑ ® U2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 a` 9N994 S WATER RD M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ® ❑ 0 N UNK VEH. ATCRASH 99-UNKNOWN Distraction N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 4 COM VEH ❑ ® U1 to i- FIRST CONTACT 7 Q 6 • E •IfYes,See Sidebar ELGIN IL 60124 0 200420F IL 2025 REAR 0 fn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)400-7678 L532-1618-2165 IL D 7GZ37TCG9LN003217 PEKIN ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 006101340 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y El N Same U1 = (UNITE (SEAT) (DOB) (SEX) SSAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),ITELEPHONE, (EMS> (HOSPITAL) I I U2 996 1- m '#OCCS > / / U1 1 m 11* I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 09/17 /2024 07 46 0 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 1 C) T 2 0 28 99 ! , 0 PM ❑Construction * N ' 3 ❑ igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 Q ARREST NAME Johnson,Annikka, P. 11-601 1535000073 / / ❑PM SLMT ® 11 1 ❑Utility p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 09/17 /2024 07 46 ®PM ElUnknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1535-Solis. Laura 801 334-Fries , , 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. 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. Z : l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' 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 ', ', ! (- 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP n • . • - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r ,-•---, ir '- DO ILCC NO. m U N XI , Source of above Z . 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 Gray WhiteEn • - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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