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HomeMy WebLinkAbout2024-00061263 , l Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill OIl III 1In ll 11111111111 lIHIUflI 11111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003565183- u, 1 U2 1 1 1 2 U1 4 U2 1 U, 1 U2 1 U,99 U2 99 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2O24-00061263 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'F'I NATIONAL ST Elgin ❑ RELATED ❑Y coN 09 24 2024 05:25 ❑AM ❑YES ®No u1 ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m 1 0(]� 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 2 N ® �Cl/MI NOS W Hendee St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS O tg DRNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 ARV ❑Rcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 2 8 /1 9 7 3 FOR DAMAGEDAREA(S) FRONT TOWED U1 DA, S. Kia Motors Col portage 2013 00-NONE 11 12 y,DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ❑IZI 0 C2I U2 2 < SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 DISTRACTED 1641 WESTMINISTER DR 105 F ❑Y ®N DUNK VEH. O ATCRASH 0 99-UNKNOWN •Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH ❑ ® 5 O ~ KNDPBCA28D7440880 Ohio Indemnity ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a Same KNDPBCA28D7440880 2 I— t HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 5 • ❑Y ®N 2 G1 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑soy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Talsma. David.W. Imo 1d o 1 9 yr 8 Ford F150 2020 00-NONE 11 r 12 1 0 ® 2 -I v 13-UNDER CARRIAGE 10 j I! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ SPDR C) E. 2009 JEFFREY LN M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 3 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR POIST CNT OONTACT 7 F O)I 6 1,S COM VEH ❑ ® U1 to If Yee,See Sidebar ELGIN IL 60123 0 3438042B IL 2025 4 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)742-8972 T425-1797-8320 IL D 0 1 FTEW1 EP6LFB65584 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 163921SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ONR Same U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (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 ❑AM Did crash occur El U2 Z N ® 11 1 91 ,4/ /024 05 31 ®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: U1 7 C) T 2 ID 28 03 ! / 0 PM ElConstruction >F c' 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 AM ❑Maintenance uz Q CO 11 1 ARREST NAME / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' ❑Utility o N ❑ ❑ SECTION CITATION NO. AM 35 2 0 ARREST NAME 9! '4/ /024 05 37 ®PM 0 Unknown work zone type U1 T 2 2 3 El • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1525-Nava.Oscar 701 - 10 /22/2024 09 00 p 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. _ F MOREany TmHANotorvehicle ONE CMVused ISto INVOLtranspoVErtD,USE SRpassengers 1050Aorproperty AD DITIONAL UNITS FORMS ; _� } A CMV is defined as D Z ' I Fhrrdes?et i j0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer and. r } ; ; ; - _Not To SC81e_j combination).or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. I d i -` ` r r r (example.shuttle or charter bus)-or n i. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� -! } } } transporting employees in the course of their employment(example.employee 0 tr -usually a van vehicle or ca i_____A____: : , 1 ii r i 4a Is usedror designated to trransport between 9 and 15rpassengers,including the driver, N !- for direct compensation(example:large van used for specific purpose) or O L____--____; . -t i } i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M m placarding(example placards will be displayed on the vehicle) 71 .:- ''' 4 4 1 / CARRIER NAME Z ' / t ADDRESS 0 Ls CITY/STATE/ZIP �•�r�♦ II,, / MOTOR CARR ID ❑ Interstate ❑ Intrastate T ❑ Not m Comm./Govt. Not in Comm./Other 1,,,,, USDOT NO. ILCC NO. m , Source of above 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? O ❑ Yes No ❑ Unknown 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 0 _ m — IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Blue 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE