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HomeMy WebLinkAbout2024-00061192 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 M ll0I fl 0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:3058 u, 9 U21 4 4 2 U, 2 U2 1 U1 99 1_12 1 u1 99 U2 1 1 12 u, 18 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00061192 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mRT20 WB El10:33 ® ❑ RELATED ®Y 0 N 09 24 2024 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m FT!MI N E S W GRACE EXIT RAMP COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 3 Cl) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n ! ! FOR DAMAGED AREA(S) .FROM TOWED U1 Q Dodge Ram 1500(pickup) 00-NONE ©, 12 , DUE TO CRASH ❑ Eg NAME(LAST,FIRST,M) Unknown.0. mo yr g 13-UNDER CARRIAGE 9 I I! 2 FIRE 0 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 76.70P 3 M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN = 8 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ii_6 Ii COM VEH ❑ 0 4 H 0 9 FIRST CONTACT 11 7 . 5 *II Yes.See&debar U1 0 2 Z ' E TELEPHONE IL Other UNK ❑Y JN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same UNK 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y El 99 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIIAV 0 NOV 0 DV /1 9 yr 9 Dodge Ram ProMaster 2021 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ ® 98 xi 0 13-UNDER CARRIAGE 10 l 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 0istraci on value 9 U1 0 i 4 CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 Z ALGONQU I N I L 60102 0 1 134299C I L 2025 FIRST CONTACT 4 7REAR'O COM VEH El 0 •If See Sidebar 0 C D IL D 0 3C6LRVAGOME552579 ACE AMERICAN INS ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = DISH NETWORK ISAH11368840 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z El N 1 ® 11 1 09,24 /2024 10 33 0 pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 22 99 N 3 ❑ 0 CITATIONS ISSUED CI PENDING + 0 pM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 -a, ARREST NAME / / El PM ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 50 t 2 ARREST NAME AM 7 r r ❑❑pM El Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 50 442-Young.Zachary 701 272-Bajak r r 0 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: Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X I- I- --I-----; - transportingtl emploned to aees1ln the course of 5 or fewer rye r emplors andyment(example:employee a contract der N } r } transporter-usually a van type vehicle or passenger car): r w i. }-----}----; - • } I- . •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C Not To Scale for direct compensation(example:large van used for specific purpose):or i. i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires /// -u placarding(example:placards will be displayed on the vehicle). ,Zmj CARRIER NAME Z 1.102..1111 ADDRESS 0 w CITY/STATE/ZIP I n MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes ® No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C 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 Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD-; ❑Yes ®No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Black 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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE