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HomeMy WebLinkAbout2024-00063382 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 1111111111111101111110110111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;2r4 u1 1 U2 1 1 1 U1 9 U2 1 U1 1 U2 U1 1 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063382 VENT * ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 CRIGHTON AVE ® ❑ Elgin RELATED ❑Y coN 10 04 2024 12:51 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR 0 SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y 21N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 0 1 / 1 3 J 1 9 4 7 Toyota RAV4 2015 00-NONE „ , DUE TO CRASH p 12 13-UNDERCARRIAGE 21 10 2 FIRE 0 ® < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 20 CRIGHTON AVE F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN CITY PLATE NO. STATE YEAR POINT OF It 6 ii_ COM VEH 0 El 1 0 ~ 2T3ZFREV6FW214221 Trumball Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 55phb315860 1 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 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV 0 NCV 0 Dv DATE OF BIRTH CIRCLE NUMBER(S) U MAKE MODEL YEAR 1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Ford C-Max 2013 oo-NONE ,t' 12 y DUE TO CRASH 0 ® 2 -I a t3-UNDER CARRIAGE 10 I! Ij 2 FIRE ❑ ® U2 XI c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 IN SPOR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O 4 •Oistrachon Value U1 0 - H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p R— IST CONTACT CITYF 8 O7 ti-6 5 CUOMYe VEH Sideba❑ ® to BH14977 IL 2024 r O See M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FADP5BU9DL515745 American Family Ins ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Sherman, Richard, M. 410939933291 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°0 NR 430 N WORTH AVE. ELG I N . IL.60123 (815)266-9721 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)IITELEPHONEI (EMS) (HOSPITAL) n I I - U2 996 r m / / - - #OcCS y 73 / /• 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 N ® 18 1 10,04 /2024 12 51 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 It YES check one below: U1 3 0 T 2 0 30 99 ! / 0 PM ❑Construction * t c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME El AM El Maintenance U2 1 a El 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N El 30 2 El ARREST NAME r / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 00 225-Wolek.Thomas 272-Bajak 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 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 4 } 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 r r 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 placarding(example placards will be displayed on the vehicle) 11 . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - 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 . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) 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? 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 Blue 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