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HomeMy WebLinkAbout2024-00063417 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III HI IIIIIII II 11111111111111011111111110111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035;T:224 u, 1 U21 1 1 1 UI 7 U2 1 U, 1 U2 1 Ut 1 Uz 1 1 11 Ut 1 Uz 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 El NOT ON S VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063417 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 RT20 EB ® ❑ Elgin RELATED ❑Y coN 10 04 2024 03:25 ❑AM ❑YES ®No u1 .< PRIVATE mo /day I yr ®PM FLOW CONDITION m ®2DQ 1 MI N E s® South State ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O .J. 1 0 / 0 9 J 1 9 8 8 Ford Explorer 2011 00-NONE 11 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 12 13-UNDER CARRIAGE 101 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 7333 SORGHUM LN M ❑Y IN NSYSTEM DUNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0 1 FM H K7D81 BGA71865 Allstate ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 802895371 1 I— t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El ®N 2 G1 ' ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) fi20 IT TOWED Y N n NAME(LAST,FIRST,M) Egetimeier.Tristan, K. mo 0 6 1d d0ay 2 D 0 3 Buick VeranO 2013 13-UNDE W 1• 12 Y REocRasH 0 ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR n E 1460 RAYMO N D ST M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 5 N CITY STATE ZIP 1II COM VEH 0 ® U1 4to INJ EJCT EPTH PLATE NO. STATE YEAR FIRST COONTACT 5 7__d 6 ® •It Yee.See Sidebar C Z SOUTH ELGIN IL 60177 0 CT80043 IL 2024 REAR 0 f0 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)715-7113 E235-8110-3165 IL D 0 1G4PP5SK5D4207886 State Farm ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 3068310-SFP-13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NEl R Same Ut _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(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 El AM Did crash occur ®Y U2 Z N ® 11 1 10;41 ;024 03 25 ®pM in a Work Zone? ❑N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 T 2 ❑ 28 99 ! / 0 PM ®Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Walker,Jordan.J. 11-601 388-1922 / / El PM SLMT o U ®CITATIONS ISSUED 0 PENDING ROAD CLEARANCE TIME ` ❑Utility o NSECTION CITATION NO. AM 55 T 2 0 ARREST NAME Walker.Jordan.J. 6-303-A 388-1923 10/4/ /024 04 11 ®PM 0 Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ®AM Workers present? ❑Y 55 388-Nelis. Ryan 701 - 10 /21 /2024 09 00 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. _ 0 IF 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i combination) or —1 INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. d i -` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.-----i-----• . + 1 r } } transporting employees in the course of their amp bym nt(exa mple employee M Not 1b Scale transporter-usually a van type vehicle or passenger car) or pt ' i . i ""= i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, - 9 W P 9 to �i�"' for direct compensation(example.large van used for specific purpose) or O L____- -1 + i } i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z .. ADDRESS 0 N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No 1 If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No P3 73 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 73 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Silver BlueEn u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Other Unknown 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