HomeMy WebLinkAbout2024-00061012 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 M U I00*1100110000
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00061012 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 09 23 2024 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin 11:51
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W 190 WB EXPY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑Mies ❑NIIv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 0NAME(LAST,FIRST,M) HOCHSTETTER.GARY.J. mD /
13-UNDER CARRIAGE 1a , 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 99 m
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :il 4 COM VEH ❑ ZgJ 1 0
" �- CRYSTAL LAKE I L 60014 0 1 0 FIRST CONTACT 12 r: _5 *If Yes.See Sidebar U1
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TELEPHONE
IL D 0 SGAKVBKDXGJ232794 PROGRESSIVE El igiJ N U2 I—
i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 951376008 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r 0 Y D N OND XI
!1 9 4 9 Nissan Altima 2013 oo-NONE ,t"i 1z..-_, DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value U1 0
POINT OF 8 )I 4 COM VEH D ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR . 6 1':_
FIRST CONTACT 4 Y :j_O ._5 ••(ryes,See Sidebar
Z ALGONQUIN IL 60102 0 1 0 BT76163 IL 2024aR
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IL D 0 1 N4AL3AP2DC190502 ERIE INSURANCE ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same Q031117393 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND❑Y 0N Ui =
;UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 09,23 /2024 11 51 ®❑PM AM in a Work Zone? ®N DIRP >
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
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2 28 99 + ! 0 PM• ❑Construction *
Z3 ❑ 1!>I CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a HOCHSTETTER.GARY.J. 11-601 w244-1771 / / PM "
-, ARREST NAME ❑
o u 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
T 2 ❑ 45
ARREST NAMEAM
x- 7 1 / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
244-Blomberg. Michael 901 275-Engelke , , ❑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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }-- -i-- --; } } } r -. , ; ; , ; ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
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3. Is
L L.___A_. 1 i. ..._.... .i transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
• � � transporter-usually a van type vehicle or passenger car):or 1:0
I- <.__-a-_-_-I , I- I- I- <--_-I--___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L L___-a____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). m,Zt
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CARRIER NAME Z
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ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
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Source of above z
. Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
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Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Blue.Dark
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 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