HomeMy WebLinkAbout2024-00062312 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III DIII III Ifi
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035/Tr403
u, 1 U2 1 1 1 U116 U2 U, 1 U2 Ut 1 U2 2 6 Ut 3 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
8
0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2024-00062312 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 71
N RANDALL RD ❑Elgin RELATED ❑Y coN 09 29 2024 05:53 ®AM ❑YES ®No U1 .<
PRIVATE mo l day I yr ❑PM FLOW CONDITION m
'COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW N
❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT 8 RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS O
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIa 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O 0
g 2022
FOR DAMAGEDAREA(S) FRONT TOWED U, O
Frei htliner C scadia 126 00-NONE 11 1 DUE TO CRASH ❑ fzi
NAME(LAST,FIRST,M) mo / day J yr 12 E
,3-UNDERCARRIAGE 1pi ®2 FIRE 0 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 181 U2 m
2048 NORTHWOODS POINTE DR M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UNKNOWN THER 916-TOP 3 Distraction Value 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 II 6 I( COM VEH ® ❑ 1 n
3AKJHHDR6NSMY6725 National Union Fire ❑' ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Hirschbach AL4594389 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
L RESPONDER
Y El N 649 E CLOVERLY RD. Fremont. NA.68025 (402)404-2000 VEHU 0
m ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 20 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi , DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE ,t 12 Xi
C
c 13-UNDER CARRIAGE 10 j I 2 FIRE ❑ ❑ 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 ❑ ❑ SPOR 0
Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 -
El
POINT OFto
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe53eeSidebarH ❑ ❑ C
1- TEAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF
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 <
OPO0NR U, _
(UNIT) (SEAT) i DOB) ISEX, (SAFT) (AIR) INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),ITELEPHONEI (EMS) (HOSPITAL) C)
W 09 /0 5/2000 M Sai Akhail/2320 N RANDALL RD .ELGIN.IL,60123/ I—
(779)775-4126 _ U2 m
/ / #OCCS D
/ / U1 1 m
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
1 1 �� 43 2 Shell Gas Station transformer box damaged 09,29 ,2024 05 53 ❑pM in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ®AM It YES check one below: U1 3 C)
T 2 ❑ 2320 N RANDALL RD ELGIN IL 60123 15 99 09 29 2024 05 56
❑PM ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM El Maintenance U2
Q 09/29/2024 06 05 ❑PM
ARREST NAME SLMT
o U 1 ❑ CITATIONS ISSUES PENDING ROAD CLEARANCE TIME 0 Utility
o N SECTION CITATION NO. AM 15
2 0 ARREST NAME 09/29 /2024 06 58 ®PM 0 Unknown work zone type Ut
T •
-- OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 ❑AM Workers present? ❑
1530 Soto,Oscar PCW 272-Bajak , El 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.
_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
N } A CMV is defined as any motor vehicle used to transport passengers or property and.
0D
II 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
-,
', combination) or —I
r INDICATE NORTH x1
Not To Scale I 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 n
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-- -- i i i- - i transporting employees in the course of their employment(example.employee ,3
transporter-usually a van type vehicle or passenger car).or w
i_____A____: : , 2320.N.Randall?Rd } r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
J 9 ? -�
for direct compensation(example:large van used for specific purpose).or O
L____-L ____ ; , i 1any
5 Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example placards will be displayed on the vehicle) 71
T.
CARRIER NAME Hirschbach Z
t ADDRESS 649 E CLOVERLY RD O
.
• ` r.
CITY/STATE/ZIP Fremont 1 NA 168025
I .!
MOTOR CARR ID ❑ Interstate ❑ Intrastate
:k1/41\
0 Not inComm./Gout. 0 Not in Comm./Other Q
USDOT NO. ILCC NO. m
XI
, Source of above Z
•
. own tank)? ❑ Yes ® No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash?
❑ 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 1 UYVS2533P2622137 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102" >102 m
T
TRAILER 1 ❑ Z ❑ z
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 53 ft 2 ft. y
Black
•
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES 2
DUE TO ❑ DISABLING DAMAGE XI DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG 6 CARGO BODY TYPE 2 LOAD TYPE 5