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HomeMy WebLinkAbout2024-00061220 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi IIII lull II 11111111111 11011011011011111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035651/7 u, 4 U21 1 1 1 Ui 7 U2 1 U, 1 U2 1 U, 1 Uz 1 1 11 U, 1 Uz 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2O24-00061220 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT N MCLEAN BLVD El ❑ Elgin RELATED ❑Y CON 09 24 2024 01:06 ❑AM ❑YES ®No u1 ,-< PRIVATE mo /day I yr 0 PM FLOW CONDITION m 1 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ® �/MI N E CI W Lawrence ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED O PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n Ford F150 2024 00-NONE FOR DAMAGED AREA(S) FRONT TOWED Ut 0 NAME(LAST,FIRST,M) .A. mo 1 2 / day J yr 0Q 0 DUE TO CRASH El ❑ ,3-UNDERCARRIAGE FIRE ❑ ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� 2 DISTRACTED 0 ISI U2 4 m 364 WALLACE AVE M ❑Y ®SNE ID UNK VEH. 9 SYTM AT CRASH D 9 99-U 15-UNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = THER '8. CITY PLATE NO. STATE YEAR FIRST CONTACT 12 7_.;POINT OF 8 . 4 COM VEH ❑ El 0 F Q:_.5 •Y Yes,See Sidebar U1 Z 1 FTEX1 LP7RKD77037 Westfield National Ins Co ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Coyote Construction CMM306860J 2 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDERN 1345 N OLD RAND RD.Wauconda. IL,60084 (847)526-1500 VEHU ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N NAME(LAST,FIRST,M) Rosal.Ana, M. mo 0 9 1d d6ay 1 9 8 4 Honda Civic 2018 00-NONE +c) 12 s REocRasH ❑❑ ® Uz 2 C v ,3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n E 4645 WHITNEY DR F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y MI9 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 I 4 COM VEH ❑ ® U1 to F FIRST CONTACT 6 Q •If Yes,See Sidebar Hanover Park IL 60133 0 EC40305 IL 2024 O C D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)379-8665 R240-0138-4864 IL D 19XFC2F56JE035327 State Farm Mutual ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same G882651F0113B BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < NR ElRE Y El N Same U1 = (UNIT( (SEAT) /DOBi (SEX) ;SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) i EMS) (HOSPITAL) I I - U2 996 1- m - #OCCS y / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 09/24 /2024 01 06 0 pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: Ut 1 T 2 CI 17 03 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 CO 11 1 ARREST NAME Furst. Robert.A. 11-601-put W1526000219 / / El PM SLMT o U ❑CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N BAM 30 2 0 ARREST NAME 1 / ptil ❑Unknown work zone type Ut T • • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 410-DeLeon.Jessica 601 272-Bajak , / ❑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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS II , r A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer l. combination)or —I r ; +, +, r INDICATE NORTH XI ;H} I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , , ,_ J. J. ', i .�� -` ` r r r (example.shuttle or charter bus)-or lwnlw97Yls X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t------i-----% 4 J -i } - i transporting employees in the course of their employment(example.employee M — — — — — transporter-usually a van type vehicle or passenger car).or w i_____A____: : i : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I ) ( IIPS ( for direct compensation(example:large van used for specific purpose).or O L____�____; 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires I I i 1 placarding(example placards will be displayed on the vehicle) Zml CARRIER NAME ' I W U ] t ADDRESS '� To . ' N7I&L.4I7& I _ (/1 o CITY/STATE/ZIP • IMOTOR CARR ID ❑ Interstate ❑ Intrastate I I • • 0 Not m Comm./Govt. ❑ Not m Comm!Other O USDOT NO ILCC NO. m 1 XI Source of above Z _ 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% 0❑ Yes No ❑ Unknown 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 Black Black u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage 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