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HomeMy WebLinkAbout2024-00061987 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111 111111111111010111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND ' LGHT COLL MANY X0O356?O25 u, 1 U2 1 1 1 U116 uz 1 ut 1 U2 99 U, 1 Uz 1 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 0 NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061987 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 WESTFIELD DR ® ❑ Elgin RELATED ❑Y co" 09 27 2024 08:03 ❑AM ❑YES ®No ut ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR CI SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® " PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑ECUES 0 SIN ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 7 / 0 4 J 2 0 0 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 . N. Nissan Sentra 2016 00-NONE 11 is i' , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10 1• 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10U2 I210 m 1084 COLORADO AVE F SYTM❑Y ®SNE❑UNK VEH. O ATCRASH D 0 99-U 15-UNKNOWN 9 76-TOP 3 Distraction Value 9 ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 6 lI 6 '( 4 COM VEH ❑ ISI 1 C) m jL FIRST CONTACT 5 7__{ 0 "If Yes,See Sidebar U1 0 Z 3N 1 AB7AP6GY278018 Geico ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 1 99 9 Same 4365148701 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU 73 L ❑Y ❑" 2 GI 0 DRIVER ® PARKED 0 CRNERLESS ❑ PEE ❑PEDAL ❑EDUCE 0 RIAV ❑Ncv 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) mo day yr Unknown Unknown 00-NONE 11_r 12 y DUE roCRASH ❑ ® 1 73 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 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑ IN SPDR C) ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-jl 6 ji 4 COM VEH ❑ ® Ut to H FIRST CONTACT 5 7 0 •If Yes.See Sidebar C REAR0 0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 Soto,Yasma 1371407-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 304 SENECA ST 5. ELGIN . IL.60120 (708)209-0899 Ut = (UNIT( (SEAT) ;DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME),(ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) n I I U2 996 ,— m / / - '#OGCS > / / U1 1 73 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 ® 18 5 09/27 /2024 08 30 0 pm in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 5 C) T 2 0 15 18 ! , 0 PM ElConstruction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 Ei AM El Maintenance U2 Q ® 11 5 ARREST NAME / / Cl PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME • ❑Utility ❑ ❑ SECTION CITATION NO. NAM 10 2 ❑ ARREST NAME 09/27 /2024 08 30 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? El Y 10 435 Mahan. David 901 334-Fries , ElPM ElN 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 ' } 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 truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' I' ` r r r (example.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir '- DO ILCC NO. m U N XI , Source of above Z ❑ 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 — X 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 -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray - 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