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HomeMy WebLinkAbout2024-00061046 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111 lIHIUflI 1111111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003565191• u, 9 uz 1 1 1 1 u,11 uz 1 U199 U2 1 U1 99 U2 1 1 9 u1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$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 • 7 [23 NOT ON SVEHICLE/PROPERTY ®OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061 O46 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 S RANDALL RD El 0 Elgin RELATED ❑" co" 09 23 2024 10_28 ®AM ❑YES ®No ut ,-< PRIVATE mo l day/yr ❑PM FLOW CONDITION m 0 /MI N E S W S artan ❑r 'COUNTY PROPERTY 23Y ❑N DOORING ❑'' #OF MOTOR 0 SLOW 1 U) ICJ P 'WITH VEHICLES INVLD 0 STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN 23Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS O D4 DRIVER ❑ PARKED ❑ORNERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. General MotorSi€uE 2017 00-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED ❑ ® U2 0 m 9 76-TOP 3 .1- M ❑Y ❑N ❑UNK VEH. AT CRASH POINT OF UNKNOWN 6 lI 6 I( COM VI EH ion�� 0 ® ALGN1 CITY PLATE NO. STATE YEAR { w 1 GTV2LECOHZ283625 N/A ❑Y ❑N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Ya Same NIA 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU .5 ❑Y ® Same" 99 0 ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIAV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Chevrolet Malibu 2004 oo-NONE 1 12 1 DUETOCRASH 0 ® 2 -I c 13-UNDER CARRIAGE Oj Y FIRE ❑ ICI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 10-TOP3 0 ® SPDR n 0 Y ® N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Oistrachon Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH 0 ® C H FIRST CONTACT 11 7__.1 8_5 •(ryes,See Sidebar CX23951 IL 2024 O (n, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 G 1 ND52F64M681796 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Spivey. Deven. M. 948858505 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 526 FRAN KLI N DR-South Elgin. IL.60177 (224)840-7593 Ut = (UNIT( (SEAT) (DOBi (SEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME 1/(ADDRESSi((TELEPHONE( (EMS( (HOSPITAL) W 06 /29/1986 M Marco a Gutierrez-Patino/953 EMERALD DR ,PINGREE GROVE.IL.60140-9112/ 996 r (309)847-9177 , U2 m / / #OCCS D / / u1 1 m I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 5 09/23 /2024 05 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 ❑AM It YES check one below: Ut 5 C) T 2 ❑ 18 99 ! / ❑PM 0 Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 5 Q 1 ® 11 5 ARREST NAME / / 0 PM 0 Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 0 ARREST NAME r / ptil ❑Unknown work zone type U1 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 10 559-Maldonado. Daniela 702 334-Fries / / ❑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 r Not To ScaleCI INDICATE NORTH combination) or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI J. .,, ', i - ` r r r (example'.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----.....---4 4 } - t transporting employees in the course of their employment ment(example.employee M Y j ; transporter-usually a van type vehicle or passenger car).or 03 C �____A____: : , It '3 ���w® . r i 4 Is used or designated to transport beMreen9 and 15 passengers,indudingthe driver,spa for direct compensation(example:large van used for specific purpose) or O L_____:_____; ; , _ i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires �s� placarding(example placards will be displayed on the vehicle) XI I. CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ElIntrastate ( 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. m XI , Source of above Z . m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown 0 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 D m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D 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 't Z White WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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