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HomeMy WebLinkAbout2024-00061204 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I III ll II 1111111111111011011111011111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY XQ03566411 u, 1 U21 3 4 2 U, 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 1 El NOT ON VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2O24I2O24-00061204 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'll RIVVER RIDGE RD El ❑gin RELATED ®Y ❑" 09 24 2024 11:04 ®AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr El PM FLOW CONDITION m 5 0/MI g N OE S W Tollgate Rd 'COUNTY PROPERTY El 21" DOORING ❑y #OF MOTOR ❑SLOW 2 C/1 WITH VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS O DA ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) FOR DAMAGED AREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) ,Joshua. B. mo 0 6 / day yr 1 0 J 1 9 9 5 Volkswagen Jetta 2024 Do-NONE 11 O� , DUE TO CRASH ❑ 13-UNDER CARRIAGE 10 DI I I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 5 m 676 ANCHORAGE CT M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value 5 ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 (� l 4 COM VEH ❑ ® 4 O VWBM7BU1 RM016043 Progressive Ins ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a Same 961 430700 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 2 0. s ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 2 / 4 J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,MI Freisinger-James, M_ 1 mo 1 day 1 9 9 1 Chevrolet Silverado 2020 00-NONE 't i 12 11'_s Re o CRASH 0 ® U2 14 C v yr 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR 1 SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 9 4 X a 16N065 US 20 HWY M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ! 4 COM VEH ❑ ® U1 to 1- FIRST CONTACT 6 7__•- ;_5 •If Yee See Sidebar Hampshire IL 60140 0 K114375 TX 2024 lop 0 99191 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)346-2884 F625-4539-1355 IL D 0 1 GCRYDED3LZ281407 Zurich American Ins ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I USIC Locating Servic BAP 9441414-09 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y 0 NR 1 165 SANTUARY DR.Alpharetta-GA.30009 (630)896-3220 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)I;TELEPHONEI (EMS) (HOSPITAL) n I I U2 996 r 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 0 Y U2 Z N 1 ® 11 1 91 ,41 /024 11 04 ❑Pti, 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 6 C) T 2 0 28 99 ! / 0 PM El Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 6 ❑AM ❑Maintenance U2 • Q ® 11 1 ARREST NAME Hernandez.Joshua. B. 11-601 254001592 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N 8 AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 254-Henke. Robert 501 393-Gutierrez I / El RA ®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. _ F 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. D Z 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r 1 i ..". l. ; 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 , f ® ® _f i r r r (example'.shuttle or charter bus)-or . •••:` \ /� / 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 , ----------+ + + \, ti• transportingemployees inof their employment(exampleXI } , t e poyees the course t e e pby ent employee J transporter-usually a van type vehicle or passenger car).or CO .. N ./, C 1 N. / i r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver, [n \ \ for direct compensation(example:large van used for specific purpose).or O -____�____� \ i 15 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m N. placarding(example placards will be displayed on the vehicle) Zl / CARRIER NAME Z To ///:// / ADDRESS '� / c) / CITY/STATE/ZIP t : / : MOTOR CARR ID ❑ Interstate ❑ Intrastate ' Not To scale L) ❑ Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7/ 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID Yes No ❑ Unknown 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 0 m X1 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Red White - 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