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HomeMy WebLinkAbout2024-00062872 1I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11 ii III Olfi Ifi 1IllIII 11111111 11111 11111 1111 1111 III Ill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY n035799933 u, 9 uz 1 1 1 1 U199 uz 1 U,99 U2 1 U,99 U2 1 4 9 U, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00062872 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 N JACKSON ST ® ❑ Elgin RELATED ❑Y co" 10 02 2024 00:43 ®AM ❑YES ®No u1 ,•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y M N DOORING ❑Y #OF MOTOR ❑SLOW 1 U1 ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES 0 NIA/ 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown 00-NONE it 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) 2 FIRE ❑ El < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 El U2 m 9 16-TOP 3 .1- ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN 6 it ii 4 COM VIER ion�� ❑ ® ALGN OF CITY PLATE NO. STATE YEAR } 6 1 F ID VIN INSURANCE CO. EXPIRED 1 unk ❑Y0 N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same unk 1 rr o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER .. RESPONDER S VEHU L ❑ Same Y ❑" 99 0 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m fim / / FOR DAMAGED AREA(S) FROM TOWED NAME(LAST,FIRST,M) mo day yr Jeep(after 19R&Jerokee 2020 00-NONE O' i'_1 DUE TO CRASH 0 ® 2 Z1 c 13-UNDER CARRIAGE 9®) ©I I 2 FIRE ElMI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN S 4 'Distraction Value 9 U1 9 POINT OF 21 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 11 r. .I 6 ! .5 •CUOM VEH Sidebar ~ DU32527 IL 2024 "E 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1C4PJMCB8LD650806 American Heartland ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 = Williams. Kabertta. L. AHQ0035974 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0"RESPONDER 327 N JACKSON 3. ELGIN . IL.60123 (779)238-2823 U1 = (UNIT) (SEAT) (DOB) ISEX) (SART) (AIR) (INJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 r m / / - #OGCS y / / 73 • U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 18 9 10/02 /2024 00 43 ❑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 1 C) T 2 0 18 99 ! / 0 PM ❑Construction * 1 c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME El AM ❑Maintenance U2 1 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 25 457-Fearo-. Megan 601 368-Davenport , / ❑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 Z ( . 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i \ INDICATE NORTH combination)or —I XI I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. \ Pa 3277N. -l' (example.shuttle or charter bus)-or r X 3 Isdesigned to carry 15fewer passengers andoperated r ----------+ + + \ -r } } } transportingemployees inof theirm in n x a or rig a by a contract Carrie0 e poyees the course a ploy e t(example employee 0 1.11 transporter-usually a van type vehicle or passenger car).or w i_____A____: : , i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N \ ( for direct compensation(example:large van used for specific purpose).or Q L_____-____; 4 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) Zml T. \ CARRIER NAME 20 .. ADDRESS C- \ • N \ F CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate Not To Scale , 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q USDOT NO. ILCC NO. XI , Source of above Z . 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 XI 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 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z WhiteEn - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE