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HomeMy WebLinkAbout2024-00061439 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III II 0 lu II 1111111111111111111 � III IIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35;2235 u1 1 U2 1 1 2 U1 8 U2 U1 1 U2 UI 1 U2 1 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$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 El NOT ON S VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) IN B Injury and/or Tow Due To Crash YR 2024I2024-00061439 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 -PI S LIBERTY ST ❑Elgin RELATED ®Y ❑N 09 25 2024 02:52 DAM ❑YES ®No u1 -< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W MAY ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR 0 SLOW CI) El 'WITH VEHICLES INVLD 0 STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) PialT TOWED Ut y- 0 . P. 0 1 / 2 8 /1 9 7 0 Ford Escape 2017 00-NONE ©' .. '�.,D DUETOCRASH El ❑ - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE- 1U z FIRE ❑ ® < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m 1125 ESSEL CT E M ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,DistractlonValue 6 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 j 6 • 4 COM VEH 0 ® 1 0 1 FMCUOF7XHUB86541 Allstate ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 062842065 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L ElY ®N 2 G1 ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) ti20Nf TOWED fi DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C c 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR n ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I 6 I. C•OM es,See Sidebar❑ ❑AR C to I— p C CA M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < D YOEl N Ut I (UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n / / U2 M / / - m #OCCS y / / U1 1 m / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ❑ 1 3 Comed ComEd Electrical Pole 91 /51 ,024 02 52 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 Fi 2 ® 31 3 2 LINCOLN CT Oakbrooldllerrace 60181 28 20 ! I 0 PM ❑Construction * t N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2 ARREST NAME Durian.Geoffrey. P. 11-601-Ax 51526000223 / / ❑PM\ 0 SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME Utility SECTION CITATION NO. o N AM 30 2 0 ARREST NAME 91 (Si /024 05 00 ®PM ❑Unknown work zone type Ut ¢ T 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? 0 Y 1526-Walsh.Jacob 401 334-Fries 10 /22/2024 01 30 0 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 _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or • INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , ._ I ', i ® r r r (example'.shuttle or charter bus)-or n S i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 ----+-----+ + + � -r } } ttransportingemployment(example employee I employeesin the course of their e e a � transporter-usually a van type vehicle or passenger car).or w i_____......--_: : i I [..! : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, r,� for direct compensation(example:large van used for specific purpose).or O L_ -:.___-1 1 ; + 1 i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) Z1 --11!— — — II I. , , .. CARRIER NAME Z ADDRESS 0 N `/Yp'7bi • CITY/STATE/ZIP - MOTOR CARR ID ❑ Interstate El intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. m XI , 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? ID 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 — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑Lr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE