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HomeMy WebLinkAbout2024-00059692 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 1111111111111110110111111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560949' u, 9 uz 1 1 1 1 U199 uz 1 U199 U2 1 U1 99 U2 1 5 12 U1 1 U223 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059692 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 AUTO MALL DR ® ❑ Elgin RELATED ❑Y co" 09 17 2024 09'30 ®AM ❑YES ®No u1 ,< PRIVATE mo /day/yr El PM FLOW CONDITION m 'COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N 0 FREE FLOW # LN5 ' 0 D4 oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑SIN ❑Rey 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 0 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE ��) IA 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 0 m r / ❑Y ❑N ❑UNK VEH. AT CRASH . POINT OFO 8 )I i 4 V 0 ®Distraction Value ALGN CITY PLATE NO. STATE YEAR { 6 i COM ER1 w F ID VIN INSURANCE CO. EXPIRED 1 Unknown ❑Y ❑N U2 I— EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L ❑Y ❑" 99 GI ®COWER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV 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) Ziobro.Zoey. L. Omo lday 2 O 0 5 Ford Focus 2014 00-NONE O' 12 1 ❑ ® 2 -I v yr 13-UNDER CARRIAGE 10) Ij 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 a 18N 303 SAWYER RD F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN II •DistracionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 11 7.'{ 6 •` ,5 C•IOMeSVEH Sideba❑ Ig1 U1 ~ Dundee IL 60118 0 EW61514 IL 2025 R O 0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)354-6276 Z160-9920-5645 IL D 1FADP3F27EL393644 State Farm Insur ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 3402282-SFP-13 Bnc ' 3 • HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y N Same U1 _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m / #OCCS ' D / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 9 09/17 /2024 10 42 ®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 ❑ 20 18 ! 1 0 PM ❑Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q 1 CO 11 5 ARREST NAME / / ❑PM 0 Utility SLMT 0 U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 'd N 8 AM 15 D T 2 El NAME 1 / ppl El Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? El Y 15 359-Willianson. Linda 901 385-Olsen I ElPM ElN 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 Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } 1 combination)or ', NoY?Drawn?ta?3cele r INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I ', d i -` ` r r r (example.shuttle or charter bus)-or n S i. 3. Is designed to carry 15 or fewer passengers and operated a contract carrier transporting -----;-----� � I A -f ) } } } 9 P transporting employees in the course of their employmentby yment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w i.____A____: : , ii 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_____�____� , , 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 Z • . d .. ADDRESS 0 ITo cn 1 o ' • CITY/STATE/ZIP •• - MOTOR CARR ID ❑ Interstate ❑ Intrastate • I 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z • . MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C z Form Number 0 _ 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black Red - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 4 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