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HomeMy WebLinkAbout2024-00063208 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 11111111111111011111011110111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003574364 u, 1 u210 1 1 1 U1 5 U2 1 u1 1 U213 Ut 1 U2 1 1 9 U1 16 U221 *PO 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El$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 [23 NOT ON S❑ON SCENE • 7 VEHICLE/PROPERTY El OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063208 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m BIG TIMBER RD ® ❑ Elgin RELATED El Y coN 10 03 2024 04:00 ❑AM ❑YES ®NO u1 ,< PRIVATE mo /day I yr 0 PM FLOW CONDITION m COUNTY PROPERTY -.Y El N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IM N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED 0 ERNERLESS 0 FED ❑PEDAL 0 EOUES 0 SIN 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0NAME(LAST,FIRST,M) mo day yr 12 .JAVIER Dodge RAM 1500(PICKUPR014 00-NONE 11 , DUE TO CRASH ❑ 21 13-UNDER CARRIAGE ��) FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑2 ® U2 0 m SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 266 ADAMS ST M PLATE NO. STATE YEAR POINT OF _II 6 li_ COM VEH 0 ® 1 0 a ~ 1 C6RR7LTXES347205 American Family ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 1132198108 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m / / y FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) mo day yr Hundai Elantra 2024 00-NONE 1 ^ y DUE TO CRASH ❑ ® 2 c 13-UNDER CARRIAGE O:i 12 !_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 0 ® SPDR n (2/ N CI UNK VEH. AT CRASH 99-UNKNOWN & 4 •Distraction Value UI 0 - ❑Y POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ ® to C FIRST CONTACT 11 7__.1 __S •Ir yes,See Sidebar N248545 IL 2025 REAR 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KMHLL4DG6RU832611 State Farm ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Fitzgerald.Virginia.J. 3369141 SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 300 W MAIN ST.ST CHARLES. IL.601 74-1 81 4 (847)529-2191 U1 = (UNITE (SEAT) (DOBi ISEXI (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMSI (HOSPITAL) n I I U2 996 1- m / / - - #OCCS D 73 / / U1 1 m / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 5 10;03 /2024 05 45 0 pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM I1 YES check one below: U1 3 C) T 2 El 06 14 ! / 0 PM ❑Construction * N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q 1 ® 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ',3N 8AM 10 2 ❑ ARREST NAME r / pti1 ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El Y 10 537-Sanders, Richard 502 334-Fries I / 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. r 0IF 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 INDICATE NORTH combination) or 'I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` 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------.-----• + + • : - -, 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 mV placarding(example placards will be displayed on the vehicle) . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP 0 . - 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 _ 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? 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 Form Number 0 m 7a 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 >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 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