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HomeMy WebLinkAbout2024-00062362 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111111111111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:4346 u, 1 U2 1 1 1 1 U1 5 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 6 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00062362 VENT * ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 S RANDALL RD ® ❑ Elgin RELATED ❑Y coN 09 29 2024 02:31 ❑AM ❑YES ®No u1 ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m O0 S W ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑ECUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 • mo day yr 12 < 13-UNDERCARRIAGE 10 2 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 4 m 7N398 WINDSOR DR F SYTM❑Y ®sNE❑UNK VEH. O ATCRASH D 0 99-15-UNKNOWN 9 16-TOP 3 "Distraction Value 9 ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 8 it 4 COM VEH 0 El 1 C) c Z KMUHCESC3PU146973 Zurich American ®Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Genesis of North Aur GP3757480-08 1 r Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDER 213 HANSEN BLVD. North Aurora. IL.60542 (630)327-2675 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 98 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N s SCOTT.JESSICA• D_ 0 8 0 3 1 9 8 3 Subaru Ascent 2019 00-NONE 1t. �' DUE TO CRASH ❑ ® , 2 n NAME(LAST,FIRST,M) mo day yr ©, Xi v t3-UNDER CARRIAGE 10 Ij 2 FIRE El MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a 12N545 JACKSON DR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF P RI8T CNT ONTACT 12 7_'1 a 1_S C•IOMesVSee Sidebar ® U1 to ~ ELGIN 60124 0 CF65440 IL 2025 REAR 9 c.n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 S300-4248-3820 IL 0 4S4WMAJD3K3402064 Erie ®Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same Q091524445 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER NEl Same U1 = (UNIT' (SEAT) (DOBi (SEX) ;SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS( (HOSPITAL) I I U2 996 1- m /• - - #OCCs D / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N i ® 11 1 09,29 /2024 02 39 ®pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 1 C) T 2 ❑ 20 06 ! / 0 PM 0 Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q El 11 1 ARREST NAME Ismajlaj.Vlora 11-709-A W499000708 / / El PM SLMT o U ❑CITATIONS ISSUED El PENDING 'SECTION • CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AM 45 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 499-Dirck Cameron 702 334-Fries I / 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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 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 truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! (- ._ ' ' '. ', ' 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 placarding(example placards will be displayed on the vehicle) 11 . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP 2 . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . 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 g Did Carrier Safety Regulations MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z White BeigeEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE