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HomeMy WebLinkAbout2024-00060403 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III IIII IIIIIII II 11111111111 1101 I iii liii 0111110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0O3561 O10* u, 1 U2 1 1 1 1 U, 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00060403 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '17 LARKIN AVE ® ❑ 4:4 Elgin RELATED ❑Y coN 09 20 2024 08 ❑AM ❑YES ®No u1 ,"‹ PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl) EP ®I MI N O S W Maple St WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 I&oRNER 0 PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EOUES 0 SIN 0 Rey 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 2 / 2 3 /1 9 6 2 FOR DAMAGED AREA(S) FRCNf TOWED U1 .James.A. Chrysler Town&Country 2015 00-NONE „ l , DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo day yr Q 13-UNDERCARRIAGE �D I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 O m 122 N SPRING ST 2N M SYSTM❑Y IN NE DUNK VEH. O ATCRASH D O 99-U 15-UNKNOWN 9 16-TOP 3 Distraction Value ALGN I THER r CITY PLATE NO. STATE YEAR POINT OF 8 iI 6 it 4 COMVEH 0 El 1 n jL FIRST CONTACT 12 7 7t___i_.5 "IfYes,See Sidebar U1 0 Z 2C4RC1 CG 1 FR584176 State Farm Ins Co ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 2084593SFP13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > >. RESPONDER Same VEHU L ❑Y ®N 2 17 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED 0 PEDAL ❑EOUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) F#0 lT TOWED , NAME(LAST,FIRST,M) Thakkar. Birju. D. mo 0 9 1d d6ay 1 9 9 7 Mazda 3 2016 00-NONE ;0 12 s FIREETocRasH 0❑ ® Uz 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n a` 218 PRESCOTT AVE M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NOto . STATE YEAR POFIRSNT T COF ONTACT 6 I7 Off •ClEyes,See Sidebar VEH ❑ ® U1 C ELGIN IL 60124 0 Q352450 IL 2025 Fly0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)810-9213 T260-0649-7264 IL D J M 1 BM 1 U70G 1295213 Travelers Ins Co ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 9940840992031 BAC 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) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EIdSI (HOSPITAL) I I U2 996 1- m - #OCCS y / /• U1 1 m 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 9/ /0/ /024 04 48 0 pm in a Work Zone? ®N DIRP co 1 r 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 ❑ 03 99 ! I 0 PM 0 Construction * N 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 • Q CO 11 1 ARREST NAME Kedzior.James.A. 11-601 W481000206 / / ❑PM SLMT o U 0 CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N B AM 30 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 481-Rodriguez. Hannah 602 - i / ❑❑PM Workers present? ®N U2 30 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 4 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z r-"--r--- 4 , r r r r r , , , 1 . r 0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -< ' r i ; i i i- r r , , i r INDICATE NORTH combination) or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- L ' ' '. ', ' I. ` 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------t-----• + + • : - -, 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 placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate • ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, i '- 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 M 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 ❑ - 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 ip Gray Red - 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