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HomeMy WebLinkAbout2024-00061155 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi III ll II 11111111111 11011101111101111111I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566416 u, 1 U21 3 4 2 U199 U2 1 Ut 1 U2 1 Ut 1 U2 1 4 10 Ut 1 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 14 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061155 VENT * ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 '11 N MCLEAN BLVD ❑Elgin RELATED ®Y ❑N 09 24 2024 07.37 ®AM ❑YES ®NO U1 -( PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W BIG TIMBER ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED O PEDAL 0 EOUES 0 NIN 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 9 / 0 2 /1 9 6 4 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 . Donna. M. Ford F150 2017 00-NONE ® 12I , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10( 2 FIRE 0 1l < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 3N708 HIGHPOINT LN F SYSTEM IN ENGAGED 15-OTHER I©9 16-TOP 3 I ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value ALGN T. CITY PLATE NO. STATE YEAR POINT OF 0!1 6 ii_ COM VEH 0 El 1 0 r' ~ 1 FTFW1 EG6HKD62158 AARP ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Same 55100383480 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑N 2 GI 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m 5 1 0 / 0 4 /2 0 0 5 FOR DAMAGED AREA(S) TOE ODRASH Y N NAME(LAST,FIRST,M) OrtIZ..IUIISSa,S. mo day yr Buick Lacrosse 2015 00-NONE 11_ 121. , ❑ ® 2 -2 13-UNDER CARRIAGE 10 t _ Z FIRE ❑ MI U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 IN SPDR SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 E. 3033 POPSIE DR F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN -OistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 T_II 6 I_5 C•IOMe6 3eeSideba❑ 21 U1 al H Belvidere IL 61008 0 V857240 IL 2024 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)990-0536 0632-4370-5883 IL D 1 G4PS5SK2F4164884 Allstate ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 974702452 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑ Same U1 = {UNIT( I SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) {EMS) (HOSPITAL) W 05 /1 4/1955 M Llyod Spencer/ 5726 W OHIO ST .Chicago.11_60613/ 996 r (331)575 2897 _ U2 m #OCCS y / /• U1 1 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POUCE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 11 4 09/24 /2024 07 37 ❑pM in a Work Zone? ®N DIRP CO 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 3 0 T 2 0 20 2 ! / 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 5 Q CO 11 4 ARREST NAME / / El PM 0 Utility SLMT p u 0 CITATIONS ISSUED ❑PENDING SECTION I CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME El Y 30 225-Wolek,Thomas 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. _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r_ __ { ' _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 0D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ✓ ' 1 - i -; ; combination) or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` I ', d i I r, -` ` r r r (example'.shuttle or charter bus)-or n T. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------:----- 1 -f } - t transporting employees in the course of their employment(example.employee 7-1 transporter-usually a van type vehicle or passenger car).or 03 ..moneneerme+ ', I I — I : : : C �____A____. : , : : 1. i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, rn — for direct compensation(example:large van used for specific purpose).or O L____ ____1 i; , "' h i 1. 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires - placarding(example placards will be displayed on the vehicle) Zml CARRIER NAME Z ' ADDRESS .Mt to wwfsr 1 Nd•arr7Aw - CITY/STATE/ZIP • MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , . USDOT NO. ILCC NO. , Source of above Z 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 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 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 Gray Whitern - 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 zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO Arties VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE