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HomeMy WebLinkAbout2024-00060416 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II .X00356101 I 11111111111 110II IIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X00356101/ u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00060416 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I LARKIN AVE Elgin ID ®Y ❑N 09 20 2024 0527 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W S LYLE AVE 'COUNTY PROPERTY El ®N DOORING 0 y #OF MOTOR ❑SLOW 1 U) ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0 1 1 / J FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) .J. mo day yr g 2011 Dodge Journey00-NONE DUE TO CRASH 11- al' -' ❑ 13-UNDERCARRIAGE 191• IDI 2 FIRE 0 ISI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 M U2 5 m 133 HINSDELL PL M ❑Y El NSYSTEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF s )� 6 1 4 COM VEH 0 ® 1 0 A ~ 3D4PG 1 FG 1 BT505249 Kemper Ins Co ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 12AU001492670 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU L ❑Y ®N 2 17 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Thirumalareddy,Joseph, R. Omoo 0 d7ay 1 9 8 5 Kia Motors Cotfiro 2020 00-NONE �0 12 Z REoCRASH ❑❑ ® U2 2 C ✓ 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C0 a` 409 BROCKTON AVE M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 4 COM VEH 0 ® U1 to F, FIRST CONTACT 6 Q 0 0•bYes,See Sidebar C ELGIN IL 60124 0 CT86786 IL 2205 0 (/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)325-2393 T654-4968-5193 IL D KNDCB3LC9L5374337 AAA ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same AUT700911671 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER Same U1 = (UNIT) (SEAT) (DOB) (SEX) )SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 03 /22/2000 F 2 4 0 1 0 Amrutha Thumma/2901 SALTKING DR,Chicago,IL,60616 996 r (203)824-6745 , U2 m / / #OCCS D / / u1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 11 1 09/20 /2024 05 27 ®pm in a Work Zone? ElN 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 El 28 03 1 / 0 PM 0 Construction * c' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 Q ® 11 1 ARREST NAME Nieves.Jose.J. 11-601-Ax 481000207 / / ❑PM SLMT o U CI CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N B AM 30 2 0 ARREST NAME / / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 ❑ 481-Rodriguez. Hannah 602 334-Fries 10 / 15/2024 01 30 El 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. _ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i i combination) or —I INDICATE NORTH XI l Nor To Sole : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ I i I j I I T I 1 I N ® -! ` r r r (example.shuttle or charter bus)-or C i_-----;-----% + _ -i } ttransporting employeeslin the course their employment(example�emaployeerier OM 3. I s ♦ 5� r nsporter-usually a van type vehicle or passenger car).or 03 i_____A____: : , r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose).or O L____-:_____; i ; , 4 r -: 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) XI ♦ —� CARRIER NAME Z ♦ ADDRESS '� _ i. . . . 1 j I j 1 � t+ a cn C� . . . . CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 0 Not in Comm./Govt. El Not in Comm./Other r , 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 D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown E Did Carrier Safety Regulations(MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 C Z Form Number D m 73 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Blue Blue - 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