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HomeMy WebLinkAbout2024-00060333 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III Ifi III ll II 11111111111 1101110111110111III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003566412* u, 9 uz 1 2 4 1 Ui 7 U2 1 U199 U2 1 U1 99 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 SCENEEl NOT ON • 1 VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00060333 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 LARKIN AVE ❑Elgin RELATED ❑y coN 09 20 2024 12:16 ❑AM ❑YES ®NO U1 .< PRIVATE mo l day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ®Y ❑N DOORING y #OF MOTOR ❑SLOW 15 N ❑ FT/MI N E S W WITH ❑ VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ❑ N PEDALCYCUST®N ❑ FREE FLOW # LNS 0 D4 ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) .0. mo day yr L General MotorkrGu p 2020 00-NONE 11 1Y y,J DUE TO CRASH p ,3-UNDERCARRIAGE 10) 2 FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m M SYSTEM IN g ENGAGED 9 15-OTHER 9 16-TOP 3 I r ❑Y ❑N ®UNK VEH. AT CRASH POINT OFWN 6 lI 6 I( COM VIion ER�� 0 ® ALGN1 CITY PLATE NO. STATE YEAR { w F ZACNJBBB6LPM00699 Unknown El ❑N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y 99 9 Same Unknown 1I— m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L • ❑Y ®N 99 0 ®COWER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Eby.James,C. lmo day yr 9 1 9 5 5 Jeep(after 198r�}legade 2015 00-NONE 1G) 12 Y DUREETo CRASH O ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 a 30 N ALFRED M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 II I, 4 COM VEH ❑ IN U1 to a� F, FIRST CONTACT 7 6 -5 •If Yes,See Sidebar Elgin IL 60123 0 M U 6506 IL 2023 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)768-3713 E100-4435-5339 IL D 0 ZACCJAAHOFPB56352 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 159-1100-B06-13G BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NEl R Same U1 = (UNIT) (SEAT) (DOB) ISEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) EMS) (HOSPITAL) I I U2 996 1- m /• - #OCCS D / /• 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 16 ®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 0 T 2 0 03 18 ! / 0 PM ElConstruction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME / / El PM 0 Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 0 ARREST NAME r / ptil ❑Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 10 451-Nisivaco. Russell 602 404-Duffy / / 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. _ 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. 1136p?LeAdn?Ave?(Jewel) z i 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', I. ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----?---.... 4 i } - i- transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w �____A____: : , i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I I I I rID I for direct compensation(example:large van used for specific purpose) or p L____ ____4 4 ; .+ i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m Not To Scale I placarding(example placards will be displayed on the vehicle) 11 I. ...' ` CARRIER NAME Z ' \ ADDRESS 0 D f/1 • L.arkln?Ave • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 I • 0 Not in Comm./Govt. El Not in Comm./Other ' USDOT NO. ILCC NO. m XI , Source of above Z • Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No P3 73 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 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 X1 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 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Gold BlueEa - 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE