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HomeMy WebLinkAbout2024-00060329 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill 010 III IIII IIIIIII II II 11111111111 IIIIIIIIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560996 u, 1 U2 1 3 4 1 U1 3 U2 3 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 2 U2 3 *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 • 3 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00060329 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I KIMBALL ST ®gin El ®Y ❑N 09 20 2024 11-57 ®AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W N GROVE ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 0 2 / 0 9 /2 0 0 5 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) g mo day yr Flores. Diego, E. Scion TC 2010 00-NONE „ Q 0 DUETOCRASH 0 fzi 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 10U2 66 m 799 PARKWAY AVE M SYTM❑Y ®SNE❑UNK VEH. O AT CRASH D 0 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER .1.' El PLATE NO. STATE YEAR • i FIRST CONTACT 1 POINT OF 6 j 6-::.5 •4 COM VEH 0 El1 O L 7_ I—— Y Yes,See Sidebar U1 Z JTKDE3B7XA031731 1 State Farm ❑Y ®N U248 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 1 99 9 Same 030025-SFP-13 1 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 DRNERLESS ❑ PED ❑PEON. ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Ventura, Meagan, E. lmo day 1 9$1 Toyota 4Runner 2012 oo-NONE 11 i 1$ '_s REo CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n a` 1224 LONG FORD CIR F SYSTEM IN O ENGAGED 0 15-OTHER 9 1 ❑Y ® 6-TO •P 3 9 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 6 1 4 H FIRST C CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT O F COM VEH ❑ ® U1 to CONTACT 5 7__L O,' •(ryes,See Sidebar E LG I N IL 60120 0 ZX35438 IL 2025 OW0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)328-7513 V536-5458-1939 IL D JTEBU5JR7C5096963 Allstate ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 Same 974248051 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < REEl Y 0NR Same U1 = (UNIT) (SEAT) (DOB) ISEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)IITELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / - '#OCCS > / / U1 1 73 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 1 09/20 /2024 12 10 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME DAM It YES check one below: U1 7 C) T 2 0 15 25 ! I ❑PM ElConstruction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2 ❑AM ❑Maintenance uz Q ® 11 1 ARREST NAME / / 0 PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility ❑ ❑ SECTION CITATION NO. N AM 30 2 0 ARREST NAME 09/20 /2024 12 10 ®PM ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 435-Mahan. David 102 404 Duffy i / 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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS passengers or property' } A CMV is defined as any motor vehicle used to transport and. Z r-"--r----, , 1 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer i ; i r r , , i combination).or —I INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '. .1 ! i L ., ' ', ', ' f ` r r r (example'.shuttle or charter bus)-or n S ; ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----1-----• + + • : ' ' 1 1 1 i } - i• transporting employees in the course of their employment(example.employee 71 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 i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 CARRIER NAME Z ' t ADDRESS 0 N . O CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not m Comm./Other Q C r---- ----, r r r r r•---, r DO ILCC NO. m • U N m , • Source of above Z IDOT PERMIT NO WIDELOAD? ❑Yes ❑No = ' TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Chrome Gray - 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