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HomeMy WebLinkAbout2024-00063120 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III II 0 lu II 11111111111111011111 III 11111 1111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035/T7369 u, 1 U2 1 3 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 Ut 3 U2 1 *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 14 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-00063120 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT E CHICAGO ST ® ❑ Elgin RELATED ®Y ❑N 10 03 2024 09:09 ®AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W N SPRING ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIN 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) 0 6 / 2 5 /1 9 5 9 FOR DAMAGEDAREA(S) FROM TOWED Ut , DELTON, L. mo day yr Chevrolet Colorado Pickup 2016 00-NONE 11 I 1 DUE TO CRASH El 13-UNDERCARRIAGE 101 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 3 m 909 BELLEVUE AVE M SYTM THER ❑Y ®SNE❑UNK VEH. O ATCRASH D 0 99-U 15-UNKNOWN 916-TOP 3 Distraction Value 9 ALGN = T. CITY PLATE NO. STATE YEAR POINT OF 6 it ' 4 COM VEH 0 El 2 0 I— FIRST CONTACT 1 7 t 1-5 "If Yes,See Sidebar U1 0 Z 1GCGTDE39G1185542 AMERICAN FAMILY ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 1 99 9 Same 075559430501FPPAIL 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 9 Same VEHU 73 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 WV ❑lav 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) DURAN-JOANA. E. 0 1 / /mo 0 8 2 D 0 1 Acura TSX 2006 Do-NONE 13-UNDER CARRIAGE © ®' _1 CRASH ❑ ®DUE TO i I FIRE ID ® U2 2 ,'a I c 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) s C DISTRACTED 0 IN SPOR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X (2/E 223 E STREAMWOOD BLVD F ❑Y N DUNK VEH. AT CRASH 99-UNKNOWN •DistracoonValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7_ 11 6 5 COM VEH ❑ ® U1 C • to If Yes,See Sidebar Z Streamwood IL 60107 0 CC63945 IL 2025 0 fp D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)201-1451 D650-4250-1608 IL D 0 JH4CL96806C034323 STATE FARM ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 DURAN, FILOMENO 0787792SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESP Y ElONDER NR 9 223 E STREAMWOOD DR. IL (630)201-1451 U1 = (UNIT) (SEAT) ;DOB) (SEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!;TELEPHONE) (EMS) (HOSPITAL) n -/ I U2 996 r m - #OCCS y / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10/31 /024 09 09 ❑pM in a Work Zone? Ill N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 5 ., a 2 ❑ 2 28 1 / 0 PM ❑Construction * '61 T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q 1 ® 11 4 ARREST NAME ROBBINS, DELTON, L. 11-901-A 374001281 / / ❑PM SLMT o uCITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility o N 0 ❑ SECTION CITATION NO. AM 25 2 ❑ ARREST NAME 10/31 /024 09 09 El pm ❑Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? El Y 25 374-Rizzu-o, Michael 101 272-Bajak 11 / 12,2024 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 ' N73PRING?ST -� A CMV is defined as any motor vehicle used to transport passengers or property and. Z j 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or INDICATE NORTH71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ' i -f ` r r r (example.shuttle or charter bus)-or 0NOf To Scale 1 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i.-----;-----% J -. i' } - i' transporting employees in the course of their employment(example.employee transporter-usually a van type vehicle or passenger car) or tp i_____A____: : , E9CHICAOO?ST { - : i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____-L____;1 i , - i ,. i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires ti • 11 • — — 1 — — — placarding(example placards will be displayed on the vehicle) 71 ',fat • ` T. CARRIER NAME Z r .. ADDRESS 0 N CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z • _ own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown E I. Did Carrier Safety Regulations(MCS)violation contribute to the crash% fl ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96" 97-102" >10:' m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Black 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE