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HomeMy WebLinkAbout2024-00061040 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II 11111111111 1101101101111101 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035651 8+ u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061 O4O VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 *Ti N LIBERTY ST Elgin ID ®Y 0 N 09 23 2024 02:57 DAM ❑YES ®No u1 .< PRIVATE mo l day/yr ®PM FLOW CONDITION m FT/MI N E S W E CH ICAGO ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N [] FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 1 1 / 1 9 J 1 9 5 9 FOR DAMAGEDAREA(S) FRONT TOWED U1 Chrysler Pacifica 2018 00-NONE DUE TO CRASH NAME(LAST,FIRST,M) , G. mo day yr ry t�- O7 -� ❑ 13-UNDERCARRIAGE ,u I 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 1002 BRUCE DR M SYM ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16-TOP 3 •Distraction Value 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF 8 iI 6 ii 4 COM VEH 0 El 3 0 A ~ 2C4RC1 BG9JR263674 Erie Insurannce ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same Q071820265 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER L ❑Y ❑N Same VEHU 2 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCV 0 ON DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m l / J FOR DAMAGED AREA(S) FRONT TOWEDi Y N NAME(LAST,FIRST,M) Oloris. Raymond.J. mo day 1 9 8 5 Ford Escape 2013 00-NONE 13-UNDER CARRIAGE tt' 12 DUE CRASH ❑ ® 6 v ! 2 FIRE El El U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 IN SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 O a` 151 DOUGLAS AVE M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RI NTST COONTACT F 6 7..�• lam!`• .6 CUOM VEH See Sideba❑r ® U1 to H ELGIN IL 60120 B R599267 IL 2024 R 0 CCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)289-2700 0462-7308-5332 IL D 1 FMCU9GX1 DUD03291 Mesirow Insurance Service ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I City of Elgin 8109160P901 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 150 DEXTER CT. ELGIN . IL.60120 (847)931-6100 U1 = (UNITE I SEAT) (DOBi (SEX) i ISAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),(TELEPHONE) (EMS( (HOSPITAL) 1 3 05 /22/1959 2 3 0 1 0 Sophie Kalina/1002 BRUCE DR.ELGIN.IL.60120 996 r (224)276-3979 _ U2 m 2 3 11 /24/1994 M 2 3 B 1 0 Damon J. Davies/151 DOUGLAS AVE-ELGIN.IL.60120 #OCCS D (847)289-2700 _ X / / Ut 2 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 23 1 1 1 09/23 /2024 02 57 ®pM 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 7 C) T 2 ❑ 28 03 1 / ❑PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q •® 11 1 ARREST NAME Kalina.Stephen.G. 11-601-Ax 51529-000103 / / El PM SLMT o U 0 CITATIONS ISSUED ❑PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N BAM 30 2 0 ARREST NAME / / ppl Unknown work zone type Ut 2 2 3 ❑ • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1529-Audi red.Jonathan 301 - 11 , 12/2024 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. _ 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer combination)or 'I r ; , 4, A ! INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', i -t ` r r r (example.shuttle or charter bus)-or r7 i 1 t .1 is. 4 : : X 3. Is designed tocarry15 or fewer passengers contractcarrier 0 gand operatedby a-----;--__-� , UNIT -! } } } transporting employees in the course of their employment(example.employee M -usually a van vehicle or passenger i.____-:----_: : , 0 ' 4' i r i 4 transporter sedor des gnated to trransport between 9 and 15rpassengers,including the driver, c for direct compensation(example:large van used for specific purpose).or O L____--___-; i . i } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI //// — 1 E-Chicago streets y CARRIER NAME • • No[ t To Scale 1 1 ADDRESS N • I • CITY/STATE/ZIP 0 r , ` MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. ,• Source of above Z . ❑ Yes 0 No ❑ Unknown A Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 rn 7a 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Blue Brown - 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE