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HomeMy WebLinkAbout2024-00063467 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111011111 III DIII III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;312' u1 9 uz 1 3 4 1 U1 8 U2 1 U199 U2 1 U1 99 U2 1 4 10 u1 1 U2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063467 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH gg 'r1 BLUFF CITY BLVD ❑Elgin RELATED ®Y ❑" 10 04 2024 07:30 ❑AM El ®No U1 .< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W ST ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EouEs 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown Do-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 3 m SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 = r PLATE NO. STATE YEAR } F ID VIN INSURANCE CO. EXPIRED 1 116 UNKNOWN Unknown ❑Y ❑N U2 I— m M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑" 99 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m 1 / / FOR DAMAGED AREA(S) TOWEDi RASH NAME(LAST,FIRST,M) Nyman, Niklas, L. 0 mo day yr 2 0 0 6 Infiniti M35X 2007 oo-NONE 1t. ,s ,I. ❑ ® 2 —I 13-UNDER CARRIAGE 10 j i 2 FIRE ❑ ICI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 0 E. 886 ARTH U R DR M SYSTEM IN Q ENGAGED Q 15-OTHER 9 IS-TOP3 0 X ❑Y ® El UNK VEH. AT CRASH 99-UNKNOWN Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7_11 a 1_5 C•IOMe6 3eeSidebaH ❑ ® U1 to C H ELGIN IL 60120 0 EX55213 IL 2025 FIEARf 0 Cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)239-8139 N550-6320-6021 IL D 0 JNKAY01 E87M308056 Allstate ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 975 017 927 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - - '#OCCS > / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 1 1 1 10,04 /2024 08 19 ®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 5 C) T 2 0 04 28 ! I 0 PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 5 Q 1 ® 11 1 ARREST NAME / / 0 PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility ❑ ❑ SECTION CITATION NO. o N AM 30 2 0 ARREST NAME 10/04 /2024 07 30 ®PM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 476-Ramos.Clarissa 401 - / / 0 PM Workers present? ®N U2 30 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. _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r_ __ 1 ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 0D I j 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I• I ; i INDICATE NORTH combination).or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', i I 0 -t ` r r r (example'.shuttle or charter bus)-or n tocarryor adesigned 15 fewer passengers and operated a contract carrier 0 tr Is < <- -`- --'. ' 9 P by } } } transporting employees in the course of their employment(example employee transporter-usually a van type vehicle or passenger car).or w i____A____: : i , : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N Ir I ,• for direct compensation(example:large van used for specific purpose).or i____--____; ; . 1 { S i } i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 placarding(example placards will be displayed on the vehicle) 71 ` CARRIER NAME Z ' t ADDRESS 0 To ahimMwr to ' • CITY/STATE/ZIP O Not To Scale MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q USDOT NO. ILCC NO. C , Source of above Z . 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 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. y Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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