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HomeMy WebLinkAbout2024-00060191 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III )III IIIIIII II 1111111111111111111011111 1111111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003 972' u, 9 U21 3 1 1 Ui 7 u2 1 U199 U2 1 U1 99 U2 1 1 11 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 El$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00060191 VEHT ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg -n S RANDALL RD ❑Elgin RELATED ❑Y co" 09 19 2024 06:30 ❑AM ❑YES ®No U1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m !-0 ® 'COUNTY PROPERTY El ®" DOORING ❑Y #OF MOTOR ❑SLOW 15 N IX IX!_ I MI N E CI W South St 'WITH VEHICLES INVLD El STOPPED U2 —I [1] AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ® N Y ❑ PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yrO .0. Unknown Unknown 00-NONE it 12 i' , DUE TO CRASH 0 13-UNDER CARRIAGE 191 2 FIRE ❑ I21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 6 m SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 I PLATE NO. STATE YEAR POINT OF I� COM VEH 0 ® 1 0 F Unknown ❑Y ❑N U2 I— m M 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 0 ' ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) MANIAGO. Laura,S. 0 o Day 1 9$8 Toyota RAV4 2020 oo-NONE 11: 1$ s FIREEToCRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 ® SPDR 0 SYSTEM INVEH. 0 16-TOP 3 0 ❑N 0 UNK - a 2609 CEDAR AVE FENGAGED Q 15-OTHER 9❑YAT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 1 COM VEH ❑ ® U1 FIRST CONTACT 6 Q •If Yee,See Sidebar to ~ GENEVA IL 60134 B CZ89727 IL 2025 i 0 fn DTELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (312)914-2211 M520-5378-8603 IL D 0 JTME6RFV7LD501850 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 0920072-SFP-13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y N Same Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - U2 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 i ® 11 1 09/19 /2024 06 35 ®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 5 C) T 2 ID 03 28 ! / 0 PM El Construction * N 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 AM ❑Maintenance uz Q 1 CO 11 1 ARREST NAME / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility o N ❑ ❑ SECTION CITATION NO. AM 45 2 0 ARREST NAME 09/19 /2024 07 11 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 45 476-Ramos.Clarissa 801 334-Fries / / p PM ®N U2 I 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. Tx Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or —I INDICATE NORTH XI Ili I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 , i N -t ` r r r (example.shuttle or charter bus)-or II edbya i netl to carry15 or fewer passengers andoperated contract Carrie 0 a i } ttransporting employee in the course of thir employment(example�emaployee XI 3 Is nsporter-usually a van type vehicle or passenger car).or w �____A____: : , i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I I I I for direct compensation(example:large van used for specific purpose).or O L____-L____; , J -: i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 '"`"' m placarding(example placards will be displayed on the vehicle) Z1 CARRIER NAME Z ' ' — — — — — ADDRESS 0 N CITY/STATE/ZIP • Not 7b Scale c MOTOR CARR ID ❑ Interstate ❑ Intrastate - ❑ Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 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 't Z Whitecn - 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