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HomeMy WebLinkAbout2024-00063478 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III II IIIIII II 1111111111111101111111111111111 TII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;;334 u, 1 U210 1 1 1 U199 U2 1 U, 1 U2 1 U1 99 U2 1 1 9 u1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 El ON SCENE[23 NOT ON 1 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00063478 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 WEST RIVER RD El ❑gin RELATED ❑Y co" 10 04 2024 09:10 DAM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 15 N ❑ FT/MI NESW 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O I&oRNER ❑ PARKED ❑ORNERLESS ❑ PEo ❑PEDAL ❑EOUES ❑MN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 . Unknown Unknown Unknown 00-NONE it 12 i' , DUE TO CRASH p 21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ lSl SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m UNKNOWN UNKNOWN F ❑Y ❑SNEM®UNK EINH. 9 AT CRASH D9 ®-UNKNOWN 8 15-OTHER16-TOP ,Distraction Value ALGN = T. CITY PLATE NO. STATE YEAR POINT OF II 6 I(_ COM VEH 0 IZI 1 0 r' ~ UNKNOWN Unknown ❑Y ❑N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 99 G� 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL 0 EOUES 0 RUV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Nissan Rogue 2019 00-NONE 1t r 12 '_1 DUE TO CRASH ❑ ® 1 —1 c 13-UNDER CARRIAGE 10 I : Y FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR— POINT OF 6 II II 4 COM VEH ❑ ® U1to FIRST CONTACT 7 Q_ 6 -5 •ItYes,See Sidebar C ZY88723 IL 2025 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KNMAT2MV8KP508403 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Jimenez. Maureen 1235168SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 433 RYERSON AVE. ELGIN . IL.60123 (312)613-6143 U1 = (UNITE i SEAT) ;DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH1 PASSENGERS 8 WITNESS ONLY (NAME)1)ADDRESS)/(TELEPHONE I (EMS) (HOSPITAL) W / / ALISON HUDD/ ..-/ U2 996 (224)944-1712 , m / / #OCCS D • 73 / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 18 9 10/04 ,2024 09 50 0 pm in a Work Zone? El 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 C) T 2 0 18 18 ! / 0 PM El Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q 1 ® 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 El ARREST NAME / I ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 537-Sanders. Richard 501 - 1 / ❑❑PM workers present? ®N U2 10 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 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 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 El 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% A ❑ Yes No ❑ Unknown 0 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ 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 BlackEn - 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