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HomeMy WebLinkAbout2024-00061651 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III )III IIIIIII II 11111111111 110111111111111111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356,9032- u, 1 U2 1 1 1 Ui 9 U2 1 U, 1 U2 U,99 U2 99 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 7 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 20241 2 024-0 0 0 61 6 51 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 -n7 BLUFF CITY BLVD ®gin El ❑Y coN 09 26 2024 12:cJ9 ❑AM ❑YES ®NO U1 -( PRIVATE mo l day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 6 co ❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ MD ❑PEDAL ❑EDDES ❑NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED U, O 11 12 ' , DUE ICI NAME(LAST,FIRST,M) Abunahleh. Mohammad, I_ mo day yr Ford F550 2021 NONE 13-UNDER CARRIAGE 1U 2 FIREETO CRASH 0 ® 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 0 m 2138 S I N DIANA AVE 3110 M SY❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 15-OTHER 99-UNKNOWN 9 16-TOP 3 "Distraction Value 9 ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 i1 6 I.4 COM VEH IZI ❑ 1 n m 1— FIRST CONTACT 99 7. 1�_5 "lives.See Sidebar U1 0 Z 1 FDUF5GN5MED22927 Acord Insurance ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR I 1 a Rad Towing 980288911 6I— m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 2205 E LINCOLN HWY. Lynwood, IL.60411 (708)800-7858 VEHU 0 13 m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 Nov ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRO 4T TOWED Y N NAME(LAST,FIRST,M) mo day yr Hino 258 2018 oo-NONE O 12 ^ -y DUE TO CRASH ❑ ® 21 xi a 13-UNDER CARRIAGE 10 i I! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0 MI SPOR n ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value 9 UI 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR I COM VEH ® 0 C FIRST CONTACT 11 7__-1__5 •Ir yes.See Sidebar 211722H IL 2024 I 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5PVNJ8JV9J4S67322 Progressive 0 y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 9 I Valla.Jaime 957639989 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 13813 S PETERSBURG DR, Plainfield. IL (408)427-5822 Ut = (UNIT) iSEAT) (DOBi (SEX) ;SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) n I I U2 996 r m / / - '#OCCS ' D / /• U1 1 m / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 18 5 09/26 /2024 01 00 0 pM in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 5 C) T 2 0 30 28 ! 1 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 AM ❑Maintenance uz Q ® 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 05 T 2 ❑ ARREST NAME 1 / pp1 ❑Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 15 430-Nemtev.Sergey 401 272-Bajak , / p PM El c 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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . r-"--r----, , 4 r r r r r , , , 1 . r } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O 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) .Z1 I. CARRIER NAME Rad Towing Z .. ADDRESS 2205 E LINCOLN HWY • CITY/STATE/ZIP Lynwood 1 IL 1 60411 o , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q C r-----.-----, r r r r r•---, i - DO ILCC NO. m U N XI , Source of above Z . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 0 >26,000 Z Were HAZMAT placards on vehicle? ❑ Yes ® No If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 7) 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 Form Number 0 M X1 IDOT PERMIT NO WIDELOAD? ❑Yes ®No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Orange White - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE