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HomeMy WebLinkAbout2024-00062815 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 M ll0I fl 11 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:30+T u, 1 U21 1 1 1 U1 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U, 13 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) Ell Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00062815 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m ® ❑ RELATED PRIVATE ❑Y ®N 10 01 2024DAM ❑YES ®NO U1 -< RT20 EB Elgin mo /day/yr 05:21 ®PM FLOW CONDITION m 010O,MI N E S © South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m M 2 4 ❑Y ❑N SYSTEM ®UNK VEH. 9 AT CRASH D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH ❑ Ea 1 O m H ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 ; _5 *Ifves.SeeSidebar U1 Z DL52621 IL 2022 E TELEPHONE IL D 0 JH4DC548365010538 None ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 eu m Ii{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMv 0 l V 0 DV 1 9 4 1 Kia Motors Co►peltos 2023 00-NONE ,�"j t2 -_, DUE TO CRASH 0 (� 2 0 13-UNDER CARRIAGE 10 l E FIRE ❑ ® U2 C c ii M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.70P 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 5 7 -�I OS •If Yes.See Sidebar C Z Crystal Lake IL 60014 0 1 0 DP29237 IL 2024 I 0 Si) Z IL D 0 KNDEPCAA0P7362163 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 2043196-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 11 1 10,01 ,2024 05 21 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 0 03 28 , , 0 PM 0 Construction * R 3 0 ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o 1 ® 11 1 ARREST NAME Victorio, Ismael 3-707 494000328 , r El PM SLMT ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility o N AM55 r 2 0 ARREST NAME Victorio, Ismael 11-710-A 494000326 , , 0 pM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 55 494-Kirsh. Katherine 701 10 ,21 ,2024 09 00 ❑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 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - c ` --I -' r INDICATE NORTH combination):or .Z-1 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.----; J i - , , transporting employeened to slin the course 5 or fewer passengers rhea emaployment nd operated xample:employee transporter anon �.neawe 6ransportet-usually a van type vehicle or passenger car):or CO L L.___a__. - 4. Is used ordesi natedtotrans rtbetween9and15rpassengers,includingthedriver, — — — unrcar t } } for direct compensation(example:large van used for speific purose):or O — �- - I 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires a � l. I placarding(example:placards will be displayed on the vehicle). 'D m XI CARRIER NAME Z ADDRESS 0 w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 r Not To Scete 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other 00 -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . • m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown T. Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE